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1 



DIAGNOSIS AND TREATMENT 
OF BRAIN INJURIES 



1 



i 



DIAGNOSIS AND TREAT- 
MENT OF BRAIN INJURIES 

WITH AND WITHOUT A FRACTURE OF THE SKULL 



BY 

WILLIAM SHARPE, M.D. 

PROFESSOR OF NEUROLOGIC SURGERY, NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL' 

CONSULTING NEUROLOGIC SURGEON, MANHATTAN EYE AND EAR HOSPITAL, HOSPITAL 

FOR RUPTURED AND CRIPPLED, BETH ISRAEL HOSPITAL, NEW YORK CITY 

AND NASSAU HOSPITAL, MINEOLA, LONG ISLAND, ETC., ETC. 



ILLUSTRATIONS 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 







Copyright, 1920, by J. B. Lippincott Company 



OCT -2 1920 



Electrotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



©CI.A576754 



PREFACE 

Within the last few years, such an advance has been made in the diag- 
nosis and treatment of brain injuries that I have considered it advisable and 
opportune to present in detail the recent developments of this subject — the 
more accurate methods of diagnosis and the descriptions and treatment of 
individual patients illustrative of the various types of brain injuries. I 
have used the designation "brain injuries" rather than "fractures of the 
skull, ' ' because in the treatment of these patients it is not so much a ques- 
tion of the presence or not of a fracture of the skull, but, of far greater 
importance, the presence or not of a brain injury, and, more important 
than any other factor in their treatment, the presence or not of an increased 
intracranial pressure, both as regards the immediate recovery of the patients 
and also their future mental and emotional status. Naturally, the treat- 
ment of the patient is not only concerned with the immediate recovery of 
life, but also the future condition of the patient — approximating and 
obtaining, if possible, a normal person after the injury. 

To facilitate its presentation, this subject has been divided into the 
following main parts. The treatment is given in general, and then in detail, 
in each case, whether the expectant palliative or the operative treatment : 

Part I. General Considerations : Pathology, Diagnosis, and Treatment ; 
Operative Technic. 

Part II. Brain Injuries in Adults. Illustrative Cases. 

1. Acute. 

2. Chronic. 

Part III. Brain Injuries in Newborn Babies and Children. Illustra- 
tive Cases. 

1. Acute. 

2. Chronic. 

A large number of individual cases has been presented in the belief 
that they will be of service to the general practitioner and to the general 
surgeon, and in the cases of brain injuries in newborn babies and children 
to the obstetrician and to the pediatrician. These patients are grouped 
according to the pathology and also to the method of treatment used ; not 
only are the "successful cases" described in detail, but also the "poor 
results" — due in many instances to the injury itself, and then, only too 
frequently in the earlier patients of five years ago, to the time and method 
of treatment employed. These patients have all been followed carefully, 
and repeatedly examined; their present condition is reported in detail. 
Post-mortem examinations were made upon all of the reported patients 
who died. Those "accident" patients having brain injuries, however, were 
in the jurisdiction of the office of the coroner, and it was not always possible 
at times to receive the necessary permission — unlike the remainder of my 
neuro-surgical work, in which no operation is performed unless a written 
permission for an autopsy (if death should occur) is given before the 



VI 



PREFACE 



operation is performed, and no operation is performed unless this written 
permission is given by the nearest relative. In those patients having acute 
brain injuries we were unusually fortunate, with few exceptions, in 
obtaining the necessary permission, and the data have^ been a source of 
much information to us in this work. 

Intracranial hemorrhage, occurring in newborn babies as the result 
usually of difficult labor with and without the use of instruments, has been 
very much overlooked and its treatment neglected in the past, and it is 
only within the last five years that the chronic conditions, resulting from 
these intracranial hemorrhages, in the form of cerebral spastic paralysis, 
mental retardation and emotional instability with and without the serious 
complication of epilepsy, have been more commonly recognized. A number 
of these selected patients, both of the acute type at birth and of the chronic 
type later in life, are described in detail — the differential diagnosis con- 
sidered and the pathology of the intracranial lesion demonstrated, either 
at operation or at autopsy. 

The condition of post-traumatic neurosis is considered in a separate 
chapter ; a number of illustrative cases are discussed in detail. 

I wish to express my indebtedness to Doctor John A. Wyeth for the 
opportunity to make these studies, and from whom I have receiyed numer- 
ous suggestions and valuable advice; his always helpful and constructive 
criticism has made this work possible; to my associates, Doctors Giles, 
Rochfort, Dunham, Lott and Espejo, for their careful, elaborate records 
and operative assistance ; to Doctors Quimby and Wei ton for the excellent 
rontgenograms ; to Doctors Hunt and Palermo for the important adminis- 
tration of the anesthesia ; and to K. S. Gardner for the accurate drawings, 
photography, and the careful reading of the proofs. 

W. S. 

May, 1920. 



CONTENTS 



PART I 

Recent Advances in the Diagnosis and Treatment of Brain Injuries 

chapter page 

I. Introduction 3 

II. General Considerations 11 

III. The Symptoms and Signs of Acute Brain Injuries 16 

IV. The Significance of Intracranial Pressure 49 

V. The Signs of Intracranial Pressure Observable in the Fundus with 

the* Ophthalmoscope 54 

VI. Intracranial Pressure as Measured bythe Spinal Mercurial Manometer 

at Lumbar Puncture 62 

VII. The Treatment of Brain Injuries With and Without a Fracture of 

the Skull 70 

A . Expectant Palliative — Successful in Two-thirds of the Patients. 74 

B. Operative — Indicated in About One-third of the Patients. 

Choice of Operation 82 

VIII. The Technic of the Operation of Subtemporal Decompression. Post- 
operative Treatment 88 

IX. Observations Regarding the Operation of Cranial Decompression 108 

PART II 
Acute And Chronic Brain Injuries in Adults. Illustrative Cases. 
X. Acute Brain Injuries 141 

CEREBRAL CONCUSSION; ITS COMPLICATIONS. THE VARIOUS INTRACRANIAL 
LESIONS, WITH AND WITHOUT A FRACTURE OF THE SKULL ; THEIR TREAT- 
MENT IN DETAIL. 
XL POST-TRAUMATIC NEUROSES 400 

XII. Chronic Brain Injuries 415 

OLD DEPRESSED FRACTURES OF THE VAULT. THE VARIOUS INTRACRANIAL 
LESIONS WITH AND WITHOUT A FRACTURE OF THE SKULL ) THEIR COMPLICA- 
TIONS. TRAUMATIC EPILEPSY. TREATMENT IN DETAIL. 

PART III 

Acute and Chronic Brain Injuries in Newborn Babies and Children. 
Illustrative Cases. 

XIII. Acute 521 

A. intracranial birth injuries; their treatment. 

B. INTRACRANIAL LESIONS IN CHILDREN UNDER 12 YEARS OF AGE." THEIR 

TREATMENT. 

XIV. Chronic 644 

4. INTRACRANIAL LESIONS PERSISTING AFTER THE BIRTH INJURY AND 
FORMING THE SELECTED CASES OF CEREBRAL SPASTIC PARALYSIS. 

B. THE VARIOUS CHRONIC INTRACRANIAL LESION'S WITH AND WITHOUT A 
FRACTURE OF THE SKULL OCCURRING IN CHILDREN UNDER 12 TSARS 
OF AGE,' THEIR COMPLICATIONS. TREATMENT IN DETAIL. 

vii 



PART I 

RECENT ADVANCES IN THE DIAGNOSIS 
AND TREATMENT OF BRAIN INJURIES 



DIAGNOSIS AND TREATMENT 
OF BRAIN INJURIES 

CHAPTER I 

Introduction 

The mortality resulting from brain injuries is very high. During the 
period from 1900 to 1910, the mortality figures at three of the large hos- 
pitals in New York ranged from 48 to 68 per cent, of all cases of brain 
injuries. In a report x published in 1916 of the Cook County Hospital of 
Chicago regarding 1000 consecutive patients having ' ' fractures of the skull, " 
the mortality was 53 per cent. This death-rate is indeed appalling, and it 
undoubtedly accounts for the attitude of many doctors and of most hospitals 
toward patients having fractures of the skull, and particularly those of the 
base : if the patient recovers, remarkable — he had a fracture of the skull ; 
if he dies — well, he had a fracture of the skull. 2 

It is this attitude of comparative hopelessness in the treatment of brain 
injuries that has allowed these patients to be almost neglected in the general 
hospitals. I well remember being severely reprimanded by my senior 
house surgeon for having admitted to the hospital from the ambulance a 
patient having "a fracture of the base of the skull," and not having sent 
the patient to Bellevue Hospital. As a house surgeon, my instructions were 
to keep the beds free of "fractures of the base of the skull," — the reason 
being that so little surgically apparently could be done for these conditions ; 
the patients either improved after a long convalescence, or more frequently 
they died — the treatment, other than the ordinary routine palliative pro- 
cedures, being of little or no benefit. 

1 Besley, F. A. : A Contribution to the Subject of Skull Fractures. The Journal 
A. M. A., January 29, 1916, p., 345. 

2 Bailey, Pearce: Diseases of the Nervous System resulting from Accident and 
Injury, 1906, p. 86. 

" In a study undertaken by me some years ago, an attempt was made to formulate 
some facts as to the fatality of brain injuries of a certain uniformity of type. Fracture 
of the base was chosen as the index, since it represents an extreme degree of violence 
and probably a similarity in the brain lesions. That this latter is true is shown by 
the greatest similarity in symptomatology, and also in conclusions as to mortality In- 
different observers. Herr in 58 cases had 29 deaths, or a mortality of fifty per cent. : 
Van Nes in 82 cases had 39 deaths, or a mortality of forty-seven per cent. : Phelps, in 
286 cases had 176 deaths, or a mortality of sixty-one per cent.: Dr. R. F. Weir and Dr. 
W. T. Bull, having kindly given me access to their histories at the Roosevelt Hospital. 
I found that 60 cases were received there during the years 1900 and 1901. By adding 
to these 9 cases of which I have private records, the resulting total is 69 cases. Of 
these 40 died, a mortality of fifty-eight per cent. Thus a fatal result is to be looked 
for in more than half of the cases of fracture at the base. The combined tables of Heer. 
Van Nes, Phelps and myself, comprising a total of 194 cases, show a mortality oi titty- 
seven per cent. In this connection it must be stated that some hospital records show 
a, much higher mortality. In the great majority of cases death is due to the injury with- 
out intercurrent conditions." 



4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

The diagnosis and. treatment of brain injuries have advanced most 
rapidly within the last few years. The clinical symptoms and signs are so 
varied and frequently so confusing in these patients that it is a most 
fascinating field; apparently in many patients the more extensive the 
fracture of the skull, the less seriously is the brain injured; and, on the 
contrary, the most dangerous of brain injuries are frequently not even 
associated with a fracture of the skull. As is well known, the fracture in 
these patients (if we exclude depressed fractures of the vault which should 
always be elevated or removed) is possibly the most unimportant part to 
be considered in the treatment, whereas the presence of a marked increase 
of the intracranial pressure, with and without a fracture of the skull, 
should immediately cause the patient to be withdrawn from that large 
group of patients properly treated by the expectant palliative method, and 
the advisability of an early operative procedure to relieve the increased 
intracranial pressure should be considered. 

In the treatment of brain injuries, with and without a fracture of the 
skull, if the patient is allowed to develop definite paralyses, a lowered pulse- 
rate, Cheyne-Stokes respiration and pulse, and that appalling' group of ex- 
treme intracranial pressure signs, then I agree entirely with the opinion, so 
commonly now held that these patients ' ' get along ' ' just as well without oper- 
ation as with operation at this late stage — the mortality being 50 per cent, 
and over ; but patients with brain injuries should not be allowed to reach 
this dangerous stage of medullary compression, due to the high intracranial 
pressure ; it should be anticipated by the accurate diagnostic methods now 
known, and if a marked increase of the intracranial pressure is ascertained, 
then an early relief of it should be advised, not only to save the life of the 
patient, but to lessen the post-traumatic conditions of changed personality, 
either of the excitable or of the depressed type, persistent headaches, early 
fatigue, occasionally epilepsy, and that long train of post-traumatic condi- 
tions in brain injuries, and due in the majority of patients to a prolonged 
increase of this intracranial pressure. 

Acute Brain Injuries in Adults. — During the past six years (1913- 
1918) I examined and treated personally 487 adult patients having acute 
brain injuries, with and without a fracture of the skull; in only 155 of these 
487 patients (that is, 31.8 per cent.) were there marked signs of an increased 
intracranial pressure, and therefore only these 155 patients were operated 
upon to relieve this increased pressure, whereas the remaining 332 patients 
did not show definite signs of an increased intracranial pressure, and were 
therefore treated by the expectant palliative method of absolute quiet, ice 
helmet and catharsis; if in shock, then the routine treatment of shock. It 
is thus seen that less than one-third of the patients having brain injuries, 
with and without a, fracture of the skull, were operated upon, and approx- 
imately this same ratio has continued during the year (1919) . It is this care- 
ful selection of patients, not only in regard to the advisability of an opera- 
tion or not, and, if indicated, then the type of cranial operation used, but 
of the greatest importance — the ideal time for performing the operation— 
these factors have made it possible to lower the mortality of brain injuries 
from the average of 50 per cent, of most hospitals to 28.4 per cent, at the 



nf 



INTRODUCTION 5 

Polyclinic Hospital, and if we exclude the non-operated moribund patients 
dying within three hours after admission to the hospital from shock, internal 
injuries, and in many cases the brain injury being but an incident in the 
patient's general condition, the mortality is lowered to only 17.9 per cent. 

We now come to the most important and difficult question in the treat- 
ment of brain injuries, with and without a fracture of the skull : " If an 
operation is advisable, when should it be performed? " This question can 
more easily be answered by stating when the operation should not be per- 
formed ; naturally, we must exclude the majority (about two-thirds) of brain 
injuries that do not have a definite increase of the intracranial pressure, and 
therefore no operation is indicated; the depressed fractures of the vault 
naturally should always be elevated or removed. 

The two periods in which an operation is distinctly contra-indicated in 
cases of brain injury are, first, the condition of severe shock in the very 
beginning, and second, the condition of medullary edema and collapse — the 
death-knell of the patient. To advise a cranial operation upon a patient — 
no matter how badly the skull is fractured nor how extensive the intra- 
cranial hemorrhage seems, and that patient is in the condition of severe shock 
with a pulse-rate of 120 and higher, then the operation at that period 
takes away whatever chance the patient may have of surviving the shock ; 
the operation is but an added shock, and merely hastens the exitus. No 
patient having a brain injury should be operated upon in this condition ; 
the mortality is most high, and if the patient does recover from an opera- 
tion in this period of extreme shock, then he recovers in spite of the 
operation. Cranial operations for brain injuries in this stage of shock were 
frequently performed in the past, and most disastrously, and thus opera- 
tions were almost discredited in the treatment of brain injuries. The natural 
reaction following these early operations in the stage of severe shock was to 
wait until there could be no possible doubt that the patient was going to die, 
unless, as was thought, a cranial operation was performed — that is, the pa- 
tient was permitted to reach the stage of medullary compression (a pulse- 
rate of 50 and below, irregular Cheyne-Stokes respiration and pulse) and 
profound unconsciousness before a cranial operation might be considered. 
This is a most dangerous stage for these patients to reach, and it is doubtful 
whether recovery can occur even with an operation at this late period, the 
mortality being very high. But if the patient has struggled through this 
period of medullary compression, and finally reaches the stage of medullary 
edema, when the pulse-rate begins to ascend quickly to 120 and higher, 
respirations become rapid and shallow — that is, the stage of medullary 
collapse — then we have the second period, when no patient should be 
operated upon; they all die, operation or no operation. T feel, therefore, 
that if these two extremes can be avoided, and the latter of these (medullary 
collapse) can certainly be anticipated in the operative treatment of brain in- 
juries, and their signs cannot be overlooked, then the rational treatment of 
brain injuries depends upon the presence or not of a definite increase of 
the intracranial pressure, whether there is a fracture of the skull or not ; in 
some of the most serious cases no fracture was present, either to he ascer- 
tained at operation in the operated patients or at autopsy. The aid of the 



6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Rontgen rays is important in the treatment of these traumatic cases only in 
patients with doubtful depressed fractures of the vault, and in latent 
fractures of the skull, where the bump is so apparently trivial that the 
patient might not be so carefully examined and treated as the condition 
would warrant ; on the contrary, no patient with high intracranial pressure 
should be obliged to wait "overnight" or for a period of hours merely to 
secure a rontgenogram of the skull. It is of no importance in the treatment 
of these acute intracranial lesions whether a fracture of the skull is present 
or not. If there is a high intracranial pressure, as shown by the ophthalmo- 
scopic examination and by the measurement of the pressure of the cerebro- 
spinal fluid at lumbar puncture by means of the spinal mercurial manometer, 
then the cranial operation of subtemporal decompression is indicated to 
relieve this increased intracranial pressure, both by enlarging the intra- 
cranial cavity and by the drainage of possible hemorrhage and cerebro- 
spinal fluid. It is not so much a question of removing the hemorrhage as it 
is of lessening the increased intracranial pressure ; whether that pressure 
is due to hemorrhage or edema, the operative indication is the same. Many 
cases of cranial injuries at autopsy have revealed no hemorrhage at all — 
merely a ' ' wet ' ' edematous swollen brain, but sufficient to cause medullary 
compression, and eventually the death of the patient. 

If an operation is considered advisable to relieve the increased intra- 
cranial pressure, the^n the operation of choice is the subtemporal decompres- 
sion and drainage. If there are no definite localizing signs of the intracra- 
nial lesion, then the decompression should always be performed on the right 
side in right-handed patients, in order to lessen thereby any possible oper- 
ative damage to the motor speech area of the left cerebral cortex/ In patients 
having depressed fractures of the vault, showing definite signs of a high in- 
tracranial pressure, it is better surgical judgment to precede the elevation of 
the depressed area of bone by an ipsolateral subtemporal decompression, so 
that, when the depressed bone is removed, there will be little or no danger 
of the underlying cerebral cortex being damaged by its protrusion upward 
through the bony opening. As the subtemporal decompression exposes a 
comparatively silent area of the brain (a portion of the temporo-sphenoidal 
lobe), its protrusion and possible damage would not appear clinically; 
whereas a partial paralysis, impairment of sensation or of vision, might 
occur, and frequently does result from operations performed over the more 
highly developed areas of the cerebral cortex. Besides, the subtemporal 
route provides not only an excellent exposure of the middle meningeal artery 
and that portion of the brain so frequently involved in cranial injuries, but it 
affords drainage to the middle fossa of the skull (the chief intracranial cis- 
tern) at its lowest point in the base of the skull. Again, the thinness of the 
squamous portion of the temporal bone makes the operation a less difficult 
one technically. The vertical incision (and not the obsolete curved incision) 
should be used not only to render the operative hemostasis more effective, in 
that the trunk of the temporal artery is clamped at its lowest point in the 
very beginning of the operation, and thus there is no bleeding from its 
branches, but the vertical incision also permits the extensive removal of the 
underlying squamous bone not only down to a level with the base of the 






INTRODUCTION 7 

skull and thereby facilitating drainage, but also as widely as is possible 
beneath the temporal muscle and yet the attachment of the temporal muscle 
to the parietal crest is left intact, so that a firm closure of its separated mus- 
cle-fibres is assured ; this is a most important factor in patients having high 
intracranial pressure, as in brain tumor, where a cerebral hernia or fungus 
might result from an imperfect closure of the temporal muscle and its fascia. 
/ The insertion of silver and celluloid plates and other foreign bodies beneath 



C 



the scalp for the closure of cranial defects is to be most strongly condemned. 



If the intracranial pressure is so high that the cerebral cortex tends to 
protrude through the bony opening, it is frequently wiser in selected 
patients to perform a similar operation upon the opposite side of the head 
immediately after the first operation. I have been obliged to do this in only 
five per cent, of the patients ; they are the ones having swollen edematous 
brains — '"water-logged," as it were — where the drainage of blood and cere- 
brospinal fluid is slight, and not sufficient to cause a marked decrease of the 
intracranial pressure. In some doubtful cases it is better judgment to wait 
for one or two days, and even longer, before the second operation is con- 
sidered advisable. The rubber tissue drains are usually removed on the first 
or second day post-operative, and the hospital convalescence ordinarily re- 
quires at least ten days or two weeks./ Naturally, these patients should not 
enter into their former active life for" a period of three months, and even 
longer ; a too early return to the strain and stress of moclern life predisposes 
them to many complaints, both subjective and objective. J Repeated examina- 
tions of the fundi of the eyes and of the superficial and deep reflexes are here 
most important in estimating the physical normality of the patient. 

Chronic Brain Injuries in Adults. — The end-results of patients having 
brain injuries, with and without a fracture of the skull, have been an inter- 
esting study. It has become quite a common belief that once a man has had a 
"fracture of the skull, " and then recovers, he is never the same person again. 
In 1912, 1 examined the records of three of the large hospitals of New York 
City during the decade of 1900-1910; the mortality of "fractures of the 
skull ' ' was 46 to 68 per cent. ; the mortality of the patients operated upon 

(was 87 per cent.) This high operative percentage was due undoubtedly to the 
operation being postponed until the extreme stages of medullary compres- 
sion and edema, and also to the fact that the operation performed was the 
"turning down" of a bone flap — a much more formidable procedure than 
a subtemporal decompression — and then the bone itself replaced, so that 
even' the benefits of a real decompression were thus prevented ; besides, in 
many patients, the dura was not opened, and, as the dura is inelastic in 
adults, therefore no adequate relief of the pressure could possibly be ob- 
tained. Of the patients, however, who were finally discharged as " well 
or " cured," I was only able to. trace 34 per cent., but of these o4 per cent. 
of the total patients found, (67 per cent,) of them were still suffering from 

^xhe effects of the injury. The chief complaints were persistent headache, a 
change of personality of the depressed or of the excitable type, and thus 
emotionally unstable ; early fatigue, making any prolonged physical or men- 
tal effort impossible, and thus the inability to work ; lapses of nunnery, spells 
of dizziness and faintness, and even epileptiform seizures in a small per- 



8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

centage of them. In examining the hospital records of the patients having 
these post-traumatic conditions, it was most interesting to ascertain, that 
these were the patients — and there were bnt few exceptions — who regained 
consciousness gradually after several days, and remained in the hospital for a 
period of four weeks and longer, whose charts made frequent mention of 
severe headache and a low pulse-rate of 60, and in some cases below 60 — 
that is, the usual clinical signs of an increased intracranial pressure; an 
ophthalmoscopic examination had rarely been made. Many of these chronic 
patients still showed the results of the increased intracranial pressure in 
their fundi and at lumbar puncture, and these were the ones upon whom a 
cranial decompression, even at the late date of several years, caused a marked 
improvement. The operative findings were always associated with a "wet," 
swollen, edematous brain. Many of the so-called post-tramautic neuroses 
are, in my opinion, frequently superimposed upon this definite organic basis 
as the result of the brain injury. The treatment, therefore, of brain injuries 
should not be limited merely to the recovery of the patient, as far as life \ 
is concerned, but it should also be directed toward obtaining a normal indi- i 
vidual, approximating as closely as possible the condition of the patient 
before the injury. 

Gun-shot injuries, as well as stab-wounds of the brain, are usually asso- 
ciated with a penetrating fracture of the skull, and therefore may be con- 
sidered in the same class as cerebral injuries following fractures of the skull. 
The greater danger of infection is present, hoAvever, and especially is this 
true when the missile has passed through the nasopharynx. Unless these pa- 
tients are treated early, they rarely recover without serious complications. 
Particularly is this so when the dura and brain have been perforated — there 
being both a wound of entrance and of exit. These patients should all be 
treated as brain injuries having an increased intracranial pressure of suffi- 
cient degree to warrant the operation of cranial decompression. I have yet 
to see a penetrating gun-shot injury of the brain which did not cause a 
marked increase of the intracranial pressure, due to the resulting cerebral 
hemorrhage and edema, unless the cranial wounds of entrance and exit 
have been of unusual size to permit excellent drainage or the shock has been 
extreme. So that, not only is the operation of cranial decompression and 
drainage usually advisable to lessen this pressure, but also as a means of 
lessening the danger and even preventing a meningo-encephalitis, so fre- 
quent in the patients who survive the initial period of shock and active hem- 
orrhage. Naturally, if the missile has passed through the basal ganglia, 
ventricles, the subtentorial tissues, and large intracerebral vessels, then the 
shock, with or without a large hemorrhage, is so rapid that these patients 
rarely survive a period of time sufficient to warrant any operative pro- 
cedure ; besides, if in severe shock, naturally no operation should be at- 
tempted, just as in brain injuries following head trauma. If the patient 
with a pulse-rate over 120 cannot react sufficiently to overcome this condi- 
tion of shock, surely no operation will assist him. If the patient does survive 
the shock, then a decompression should be performed, and, if necessary, a bi- 
lateral decompression, and both the skull openings of entrance and exit 
should be enlarged with rongeurs, " cleaned " as well as possible, and rub- 



INTRODUCTION 9 

ber tissue drains inserted. By no means should the brain be probed or 
■ ' explored ' ' for bone and bullet fragments, as more damage, such as an in- 
crease of the cerebral hemorrhage and especially the edema, as well as a 
direct destruction of the delicate nerve-tissues, usually results from such 
procedures. There is little danger from subcortical foreign bodies other than 
that of infection, and the mere removal of the foreign body does not lessen 
that danger, as it would have occurred at the time of the injury. Such med- 
dlesome procedures, especially when the patient is in the stage of initial 
shock, merely hasten the death of the patient, just as in brain injuries 
following cranial trauma, if the patient is in severe shock, treat him for 
shock, and "let him alone" — not even careful neurological examinations 
to ascertain the exact cerebral status ; such examinations of a patient in 
severe shock surely do not benefit the patient, and undoubtedly they lessen 
his chances of surviving the shock. If, however, the patient can overcome 
this condition of shock, then he should be most carefully examined, and the 
proper treatment of the local injury instituted as soon as possible. 

On account of the serious and most extensive cranial injuries occurring* 
in the world war and resulting in large cranial and cerebral defects, there 
has been a tendency to forget some of the underlying principles of brain 
surgery, as though the principles of neurologic surgery were not the same as 
in civil life. The methods may vary in individual patients, owing to the ex- 
treme character of many cerebral injuries in the war service, yet the oper- 
ative treatment of these patients is based upon the presence of intracranial 
pressure, with the much greater danger of infection and loss of cerebral 
tissue; otherwise the treatment is essentially the same. To excise brain 
tissues freely, as if they were so much muscle or fat, when macerated and 
apparently infected, is undoubtedly necessary and advisable in selected 
patients, but to state that cranial injuries in the war service should be treated 
in this manner, as though it were the usual method of treatment of brain 
injuries, and that this method should be used in civil life, cannot be con- 
demned too strongly. Naturally, the greater danger of infection of war 
wounds of the brain make these cases very serious ones indeed, and yet if 
the cardinal principle of lowering the increased intracranial pressure in the 
treatment of these selected patients by a large cranial decompression is ob- 
served, even these patients will be given a greater and a definite chance 
of recovery. 

Brain Injuries in Newborn Babies and Children. — The symptoms and 
signs of brain injuries in newborn babies and children are in many ways so 
different from those following similar injuries in adults that it is necessary 
to devote to them a separate chapter. 

Acute Brain Injuries in Babies. — Tn babies, owing to the open fon- 
tanelles and to the greater elasticity of the dura, the immediate symptoms 
and signs of brain injuries are often so mild that they are frequently over- 
looked, unless most careful and thorough neurological examinations are 
made, and certain special aids of diagnosis utilized, sueli as the ophthalmo- 
scope and the examination of the pressure and oi' the cerebrospinal fluid 
itself at lumbar puncture by means of the spinal mercurial manometer. 
These intracranial lesions may escape serious attention (ov a period of 



to DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

months in new-born babies and of even years in many children until the con- 
dition of cerebral spastic paralysis and its allied impairments, both physical 
and mental, appear. Repeated lumbar pnnctures alone may be sufficient 
for drainage of the acute intracranial condition of hemorrhage and cere- 
bral edema. 

Chronic Brain Injuries in Children. — The remote effects of brain in- 
juries in babies and children, such as spasticity, mental impairment in many 
patients, and frequently epilepsy, are merely reminders of the former intra- 
cranial damage, usually a supracortical hemorrhage and we should be most 
careful in our examinations and treatment to anticipate these frightful 
sequelae. The older the children following intracranial birth, traumata and 
the longer the period of time since the injury in the older children, the less 
hopeful is the prognosis. These late patients are derelicts, as it were, and 
can merely be improved; whereas if the condition of cerebral hemorrhage 
and edema is recognized as early as possible after the intracranial lesion has 
occurred, and if there is a marked increase of the intracranial pressure and 
the proper operative treatment of cranial decompression and drainage in- 
stituted, then in these patients so treated not only will the ultimate improve- 
ment be greater, and even a cure may be obtained, but also the imme- 
diate recovery of life be greatly enhanced. These lesions in babies and 
children have been so overlooked, and even neglected, that it seems advisable 
to report a large number of these cases in detail. Naturally, the older the 
child, the more do the symptoms and signs of an intracranial lesion resem- 
ble those occurring in an adult, and yet the brain in* children under the 
age of puberty is so adaptable to changed conditions, and to a certain extent 
less delicate, that even a high degree of intracranial pressure, due to hemor- 
rhage and cerebral edema, may present clinically few signs of its presence, 
and in many patients it can be withstood, and undoubtedly is successfully 
drained, by natural absorption alone. This fact should always be remem- 
bered in the treatment of brain injuries in children, so that no operation 
should be advised unless the intracranial pressure in these patients is very 
liigh, and when it is doubtful whether the child can ""take care of" this 
increased pressure alone and even with the aid of repeated lumbar punc- 
tures daily. Thus does the treatment of brain injuries in children differ 
from that in adults. Naturally, just as in adults, all traumatic depres- 
sions of the vault, with or without a definite fracture of the bone itself, 
should be elevated or removed; in babies, the use of forceps in difficult 
labor frequently produces a definite depression of the vault without a 
fracture of the bone itself, owing to its greater resiliency, and unless 
this depressed area of bone is elevated or removed, the danger of future 
cerebral impairment is great indeed. It is frequently not necessary to 
open the dura in these cases of local depression of the vault in babies, 
as subdural and supracortical hemorrhage rarely results from it. Naturally, 
in cases of doubtful subdural hemorrhage and cerebral edema, the dura 
should always be opened through a subtemporal decompression, just as in 
adults having an increased intracranial pressure associated with a depressed 
fracture of the vault, and then the local bony depression elevated or removed. 



■■ 



CHAPTER II 



General Considerations 

The entire subject of brain injuries has been so obscured and confused 
by the question, " Is a fracture of the skull present ? ' ', as though the presence 
or not of a fracture of the skull were the important factor of cranial injuries, 
that the progress in the diagnosis and treatment of brain injuries has not 
been commensurate with the advance made in the other branches of medicine 
and surgery. Before the extensive use of the Rontgen ray, patients having 
brain injuries, if the depressed fractures of the vault are excluded, were 
possibly more rationally diagnosed and treated in many hospitals than 
they have been within recent years under the most modern development 
and accuracy, of rontgenograms ; so frequently, it is still asserted, following 
cranial injuries with negative rontgenograms, that "as no fracture of the 
skull is revealed by the X-ray, the condition is not a serious one, ' ' and the 
converse with positive rontgenograms that, ' ' the condition is a most serious 
one in the presence of such an extensive fracture of the skull." These 
statements are also frequently made in court, while the positive X-ray 
pictures are shown impressively to the judge and jury. 

It is now well known that severe brain injuries need not be associated 
with a fracture of the skull; that a positive rontgenogram (unless it dis- 
closes a depressed fracture of the vault) in no way lessens the effectiveness 
of the expectant palliative treatment, but that it frequently aids this medi- 
cal treatment by permitting the drainage of intracranial hemorrhage and 
cerebrospinal fluid through the lines of fracture into the subcutaneous tissues 
of the scalp, where hematomata of varying sizes may be formed, or into 
the nasal cavity and most frequently into either auditory canal. In this 
manner, the increased intracranial pressure is lessened so that the mechani- 
cal operative relief of the intracranial pressure, whether due to hemorrhage 
or cerebral edema, is rendered unnecessary and thus a cranial operation 
is avoided ; and on the contrary, if there is no line of fracture of the skull 
present, then whatever intracranial hemorrhage or cerebral oedema occurs 
following a cranial injury is in no way drained and lessened other than 
by the natural means of absorption through the cortical veins, sinuses and 
possibly lymphatics; and should this method alone of lessening the intra- 
cranial pressure prove insufficient, then the operative mechanical method 
of drainage would be advisable in order to obtain the best result — not only the 
recovery of life of the patient, but, of almost equal importance in many of the 
patients, the return to a normal condition, both mentally and physically, as 
before the cranial injury. To advise a cranial operation just because the 
rontgenogram reveals a fracture of the skull (in the absence of a depressed 
fracture of the vault) is most strongly to be condemned — no matter how ex- 
tensive the line or lines of fracture are; in fact, the more extensive they arc 
the greater the probability of their permitting the intracranial hemorrhage 
and cerebral edema to escape extracranially and thus the serious condition 
of intracranial pressure and medullary compression be avoided. Lines of 

ii 



12 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

fracture, however, extending into the posterior fossa subtentorially are 
usually most serious types of fracture on account of the greater danger of 
subtentorial hemorrhage and edema producing a direct compression upon 
the medulla itself , although even in these patients this increased subtentorial 
pressure is occasionally entirely relieved by the drainage of the hemorrhage 
and cerebrospinal fluid through the lines of fracture and into the tissues 
at the base of the neck. Conversely, not to advise a cranial operation in 
the presence of a high intracranial pressure, whether due to hemorrhage 
or cerebral edema, merely because of the absence of the usual and historical 
signs of a fracture of the skull, such as a bleeding and discharge of cerebro- 
spinal fluid from the nose and ears, subconjunctival and mastoid ecchymoses, 
and a line of fracture of the skull is not revealed in the rontgenograms, is 
equally to be condemned. Most of the mistakes in the diagnosis and treat- 
ment of brain injuries occur in this class of cranial injuries, and especially 
in those patients of middle-age and older, associated with other conditions, 
particularly chronic alcoholism, chronic nephritis, and arteriosclerotic con- 
ditions ; it is in these patients that the acute condition of "wet" brain (acute 
cerebral edema) occurs so easily and most frequently following cranial 
injuries of apparently trivial character and not even of sufficient force to 
produce a fracture of the skull. If careful and repeated examinations are 
made, however, the preliminary stages of these conditions can be recognized 
early, the proper treatment instituted and thus the advanced and extreme 
condition of "wet" brain can be early relieved, if not even anticipated 
and avoided. 

Careful rontgenograms, however, should be made in different planes of 
all patients having cranial injuries, no matter how trivial apparently, in 
the knowledge that if a line of fracture is disclosed, then the patient will 
receive much more careful examinations and treatment — the doctor realizing 
that the cranial injury was of sufficient force to fracture the skull, with 
possibly intracranial damage and complications, so that the after-treatment 
and advice will also be more careful; naturally depressed fractures of the 
vault must be ascertained in all cases of cranial injury and the appropriate 
treatment of elevation or removal of the depressed area of bone early per- 
formed. The treatment of patients having cranial injuries, therefore, should 
not be delayed in the absence of rontgenograms, and especially when associ- 
ated with a high intracranial pressure, and the presence or not of a 
fracture of the skull (if the depressed fractures of the vault are excluded) 
should not in any way predispose the doctor toward the method of treat- 
ment — whether the expectant palliative treatment or the operative method 
of subtemporal decompression and drainage is adopted. No cranial opera- 
tion should ever be performed upon these patients in the absence of high 
intracranial pressure unless there is a depressed fracture of the vault; 
merely a slight increase of the intracranial pressure, whether due to hemor- 
rhage or cerebral edema, is usually "taken care of" by the natural means 
of absorption alone, and if there is no increase of the intracranial pressure 
at all, naturally no operation of cranial decompression is necessary. The 
operation is to relieve intracranial pressure both by a simple decompression 
and by drainage; bux if there is no pressure present, it of course cannot 






GENERAL CONSIDERATIONS 13 

relieve it, and therefore the operation would be an unnecessary and med- 
dlesome procedure — at best the operation should not then be called a 
"decompression." This criticism is applicable to the so-called "decom- 
pression and drainage ' ' of cases of internal capsular hemorrhage occurring 
in the usual type of apoplexy — and even in the absence of an increased 
intracranial pressure ! 

The presence of paralyses of the cranial nerves, in the absence of a 
marked increase of the intracranial pressure, is due to a direct injury 
to the cranial nerves themselves, and in conditions of paralyses of the 
extremities the usual cause is a cerebral laceration and contusion. Of the 
cranial motor nerves, the motor oculi (III), the abducens (VI), and particu- 
larly the facial (VII), are most frequently involved, the impairment being 
either a severance of the nerve itself and therefore a permanent paralysis, 
or more frequently merely a compression of it by hemorrhage and, in the 
case of the facial nerve, in its bony canal of the aqueduct of Fallopius, by 
edema and therefore usually a temporary impairment only ; whereas in para- 
lyses of the extremities in the absence of a definite increase of the intra- 
cranial pressure, a cerebral laceration of the cortical and subcortical type 
should be suspected. In conditions of hemiplegia (if no increased intra- 
cranial pressure is present) , a. lesion of the internal capsule itself must be 
considered. Naturally, in these acute paralytic conditions in the absence of 
a high intracranial pressure, no cranial operation is indicated. (It is possible 
for a small cortical hemorrhage to be the cause of the monoplegia and yet 
no marked signs of an increased intracranial pressure be present. In care- 
fully selected cases a cranial operation might be advisable for these patients, 
although the majority of them recover, without any cranial operation, by 
the means of natural absorption alone.) It is a rule, therefore, only in these 
patients having paralysis in whom there is a marked increase of the intra- 
cranial pressure, that a cranial operation is indicated. 

The above method of procedure is equally true of patients having con- 
vulsive seizures; if there are no marked signs of an increased intracranial 
pressure, then it is unwise to advise a cranial operation, unless the convul- 
sions are of a very severe and persistent character. One or two attacks 
within several days following an acute cranial injury should not make a 
cranial operation advisable, especially in the absence of an increased intra- 
cranial pressure. (Naturally, if a depressed fracture of the vault should be 
ascertained, it should be immediately elevated or removed.) 

Types of Fractures of the Skull 

Fractures of the skull may be classified briefly according to their location 
"direct" fractures occurring at the immediate area of contact, and the "in- 
direct" fractures occurring at various distances from this area of contact. 

I. Direct Fractures. — The "direct" or local fractures may consist 
of a break of the outer table or of the inner table of the skull, or of both 
if the impending force is sufficiently strong. If the surrounding outer tabic 
is broken, a partially depressed fracture may result: if the surrounding 
inner table is also broken, then a completely depressed fracture is possible: 
if more than one fragment is present, the term "comminuted" fracture may 



i 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



be used, (Figure 1 demonstrates the various degrees of ' ' direct ' ' fractures. ) 
Thirty-six of iny operated patients represented different degrees of direct 
or local fractures. 

II. Indirect Fractures. — The "indirect" fracture is usually a linear 
one — extending away from the area of contact and most frequently down 
into the base of the skull, especially into the middle fossa. My experience 

has been that it is rare for a fracture to be 
limited to the vault alone, whether the 
fracture be a simple linear one — a ' ' crack ' ' 
— or one with depression ; it will usually be 
found that a line of fracture extends from 
the thicker bone of the vault down to the 
thinner bone of the base, and this is what 
we should naturally expect. Eighty-five of 
my operated patients were of this type. 

Many theories have been evolved to ex- 
plain this tendency of fractures to radiate 
to the base. It was a common observation 
f* ^^T^Siii^^Jj^^v^^ that if the cranial vault was struck by a 

fairly pointed object, then a localized de- 
pression or even a perforation would result, 
and possibly a line of fracture would extend 
downward into the base; however, if the 
cranial vault was struck forcibly by a 
blunter, wider surface, then there might not 
be a localized depression, but a line or lines 
of fracture would extend downward into the 
base and up to the opposite side, the lines of 
fracture tending to merge at a point directly 
opposite the area of contact by the object. 
This radiation of the lines of fracture and 
their tendency to merge on the opposite 
side, producing what has been termed the 
fracture of " contre-coup," are most satis- 
factorily explained, in my opinion, by the 
"bursting" effect of injuries of the cranial 
cavity. When the head is forcibly struck 
against a hard object, the point of contact 
tends to be approximated to its pole on the 
opposite side, and so mechanically there is a 
tendency for a line of fracture to occur in one of the meridians extending 
from the point of contact to its opposite pole ; as the base, especially its middle 
fossa, is much thinner and weaker than the bone comprising the vault of the 
skull, naturally the line of fracture extends downward into the base, and the 
so-called ' ' fracture of the base ' ' results. The line of fracture may, however, 
merge into one of the sutures of the vault of the skull, producing the so-called 
* ' fracture by diastasis, ' ' which most frequently occurs in children. 

These lines of "bursting" fractures of the skull usually extend down- 




Fig. 1. — Local depressed fractures of 
the vault; the mechanics of their produc- 
tion. A, the normal vault, with its outer 
and inner table, and the interposed diploe 
The arrow indicates the force applied at 
the point of contact, and the lines 1-3 and 
2-4 are placed at right angles to both the 
outer and inner tables; naturally they con- 
verge. B, the force applied at the point 
of contact produces a depression of both 
the outer and inner tables, and especially 
of the inner table, as shown by the diver- 
gence of the lines 1-3 and 2-4. C, the 
inner table may fracture and a fragment 
may be depressed, and yet the outer table 
may remain intact, either depressed or, as 
illustrated here, in its original position. D, 
a complete depressed fracture occurs when 
the force applied is sufficient to cause a 
fracture not only at the point of contact 
but also at the margin of the depressed 
area; the fine of fracture of the inner table 
is always beyond that of the outer table. 



GENERAL CONSIDERATIONS 15 

ward into the middle fossa through the petrous portion of the temporal bone, 
rupturing the tympanic membrane and thus allowing blood from the middle 
ear, and even cerebrospinal fluid, to escape at the external auditory meatus. 
If the line of fracture extends into the anterior fossa, then the cribriform 
plate of the ethmoid bone, being the thinnest and weakest portion, is usually 
' ' cracked, ' ' producing bleeding from the nose. Mere bleeding from the nose 
or from the ears, however, does not necessarily indicate a fracture of the base 
of the skull, because the blood may result from a local injury to the nose itself 
or to the external auditory canal; if, however, cerebrospinal fluid is also 
observed, then a fracture must be present. Extreme care should be used 
in ascertaining a rupture of the tympanic membrane because of the great 
danger of infection ; it is much wiser merely to wipe the external auditory 
meatus with sterile cotton and not attempt to introduce instruments for an 
otoscopic examination; naturally, if there is no bleeding from the ear, an 
otoscope can be used without danger of infection, and frequently blood 
in the middle ear will be diagnosed by the bluish color of the tympanic 
membrane, which has remained intact. 

In this series of 155 operated patients, the area of contact was in the 
parietotemporal region in 71, and in 49 of these a line or lines of fracture 
extended downward into the middle fossa or forward into the angular 
process of the orbit of the same side. In 68 of the patients having a fracture 
of the base of the skull and in whom no signs of fracture of the vault were 
ascertained, in performing a subtemporal decompression, I found a line 
of fracture extending upward into the vault in 25 of them. Fractures of 
the frontal region most frequently radiate into the orbital bones and into 
the anterior fossa, producing marked orbital signs and a hemorrhage and 
leakage of cerebrospinal fluid into the nasal cavity. 

Fractures of the posterior portion of the vault beneath the tentorium 
usually send lines of fracture, when they do radiate, downward toward the 
margin of the foramen magnum, and frequently beyond it into the basilar 
process. This type of fracture is the most serious of all cranial fractures, 
due chiefly to the great danger of medullary compression and collapse result- 
ing from the pressure of hemorrhage or edema beneath the tentorium 
directly upon the medulla. The signs of medullary edema in these patients 
usually appear very soon after the injury, and death frequently occurs 
within three hours. A subtentorial decompression in these patients offers 
what little chance there is for recovery. Eight of the operated patients that 
died revealed at autopsy this type of fracture of the occipital bone and its 
basilar process and associated with large subtentorial hemorrhage. 

It is interesting to note that a most common site for "direct" depressed 
fractures is in the upper posterior portion of the vault, about the posterior 
fontanelle, and yet the lower occipital area surrounding the foramen 
magnum is so well protected by large bony buttresses that the lines of 
fracture in these patients radiate most frequently forward into areas of com- 
parative safety rather than backward into the occipital bone beneath the 
tentorium — a most dangerous area. 



CHAPTER III 

The Symptoms and Signs of Acute Brain Injuries 

I. Symptoms of Acute Brain Injuries. — The initial symptoms of ^cute 
brain injuries are few. Most of these patients are unconscious for varying" 
periods of time, so that their subjective sensations, if any, are not com- 
municated. Upon being aroused from the condition of unconsciousness, 
which usually occurs within several hours after the cranial injury, or 
shortly after the decompression in the operated patients, these patients 
are in such a stuporous, drowsy condition, and their mentality is so con- 
fused, that they have great difficulty in making known their complaints. 
If they do recover consciousness sufficiently to make themselves understood, 
then the chief outstanding complaint, which is always present, is headache 
of varying character and degree. It frequently happens that many patients 
having most severe brain injuries are not even rendered unconscious, or, 
if so, then for several minutes only ; these patients, however, all complain 
of the most intense piercing headache, which usually increases as their 
entire consciousness more fully returns. 

1. Headache.— Headache of a ''throbbing," "beating" character is 
practically always present. At times it is only a dull, heavy feeling in the 
very mild cases, while in the patients who still remain conscious it is very 
severe and intense — the typical "splitting" headache; the resulting rest- 
lessness may be extreme. The headache of these patients is now known to be 
due to tension upon the dura resulting from the mild increase of the intra- 
dural pressure from hemorrhage, and, more usually from a cerebral edema 
of varying degree — that is, an increased amount of cerebrospinal fluid, 
due to a temporary cessation of its excretion into the cortical veins, sinuses, 
etc. In the mild cases, the headache persists for several days only, and 
gradually lessens as the increased amount of cerebrospinal fluid, clear or 
blood-tinged, is absorbed by the cortical veins and sinuses. If, however, 
the cranial operation of subtemporal decompression is necessary to relieve 
the high intracranial pressure, then the headache disappears, almost imme- 
diately following the operation. This observation is most impressive and 
striking, and it is the usual history. 

2. Nausea and Vomiting. — Nausea is very common, and if the injury 
has been received two or three hours after a meal, then vomiting may occur. 
Too much importance, however, has been placed in the past upon the 
symptom of nausea ; in my experience, it is associated with any condition 
producing shock, whether the injury be cranial, abdominal, or elsewhere. 
It is no index of increased intracranial pressure unless in the extreme cases, 
and in subtentorial lesions about the medulla, when it is always associated 
with vomiting. Chronic alcoholism predisposes many of these patients to 
the excessive nausea and vomiting which otherwise would only occur infre- 
quently in the more temperate patients having the cranial injuries. 

II. Signs of Acute Brain Injuries. — It is upon the signs of brain injuries 
that the greatest importance must be placed in their diagnosis and treat- 
16 






THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 17 

ment. The signs of cranial injury are many and multiform, whereas those 
of brain injury are comparatively few, but most important. It must always 
be remembered that a brain injury is not necessarily present merely because 
the vault or the base of the skull is fractured or the head is badly lacerated 







Fig. 2. — William W. Large linear fracture of the vault — at least one-quarter of an inch in width and 
extending from the right frontal bone backward into the right occipital area, in a boy of eighteen years 
of age, who walked into the accident room of the hospital complaining of a "soreness in the head " following 
a fall of almost one hour previously. Upon examination, there were no positive neurological signs; the 
ophthalmoscopic examination was negative, and the spinal mercurial manometer registered a normal 
pressure (8 mm.) of the cerebrospinal fluid, which was clear. No operation; expectant palliative treatment. 
Uneventful recovery after a period of ten days in the hospital. Present condition — excellent. 

(Fig. 2), and conversely, that a brain injury may, and frequently does, 
occur without there being- a fracture of the skull or the other signs of an 
external cranial injury (Fig. 3). 

A. Local Signs. — A cranial injury of sufficient force to produce a 
brain injury, with and without a fracture of the skull, usually damages the 
tissues of the outside of the head to a greater or less extent. Such eon- 
fusing contusions, however, must be rigidly excluded in making a diagnosis 

2 



18 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




Fig. 3. — Henry W. Extensive supracortical and subarachnoid hemorrhages associated with acute 
medullary edema, but no fracture of the skull, in a man who had fallen, while asleep, from a fire-escape 
to the ground — a distance of twelve feet; marked stupor upon admission to the hospital two hours after 
the injury (2 a.m.). As there were no signs of a "fracture of the skull, " such as bleeding from the nose, 
mouth or ears, et cetera, and since the general condition of the patient "seemed good," it was decided to 
"wait until morning" and then have an "X-ray picture taken." At 7 a.m. (5 hours after the injury and 
3 hours after admission), the patient suddenly developed extreme signs of an acute medullary edema — the 
pulse- and respiration-rates quickly ascending to 150 and 50 plus, respectively, so that death occurred 
at 10 a.m. (8 hours after the injury and 6 hours after admission to the hospital). An autopsy did not reveal 
a fracture of the skull. Careful repeated examinations could have, at least, anticipated this unfortunate 
result. 



i 




• u ' 4 - — Trieodor e A. Multiple hematomata of the scalp and a large hemorrhage into the right orbit, 
with resulting exophthalmos in a youth sixteen years of age, with profuse bleeding from the left ear and 
left nostril upon admission to the hospital, and yet no fracture of the skull could be demonstrated either 
b y ^~ r . av or at the later operation of right subtemporal decompression; a very "wet" edematous brain 
producing signs of a high intracranial pressure was revealed and drained — permitting an excellent 
recovery. Otoscopic examination disclosed an intact left tympanic membrane and merely a laceration 
of the posterior wall of the left external auditory canal. 



ffiSfi 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 19 

of a fracture of the skull. Ecchymoses about the orbits and mastoid 
regions, and hemorrhage from the nose, mouth and ears, are frequently 
the result of local injuries, and in no way associated with a fracture of the 
skull (Fig. 4). Hematomata of the scalp, especially if subpericranial, may 
easily simulate depressed fractures of the vault; and the reverse is also 
true in that linear fractures of the vault of varying degree are frequently 
concealed beneath hematomata (Fig. 5). In doubtful cases of depression 
of the vault, the head should always be shaved, and an exploratory incision 
through the scalp made to ascertain the presence or not of a bony depres- 
sion; a careful bimanual palpation of the head is very important in all 
of these patients. 

Any bleeding coming from the nose, throat or ears should have its 
source investigated, but always under the most rigid asepsis. If cerebro- 
spinal fluid is observed, then a fracture of the skull must be present. Sub- 
conjunctival hemorrhages, as well as ecchymoses in the mastoid areas, 
appearing soon after the accident, without a local contusion being present, 
are suggestive of a basal fracture. If these signs appear after one or two 
days, they are especially indicative. It is possible, however, to have exten- 
sive subconjunctival hemorrhages, and yet there is present no fracture of 
the orbital bones. This observation has been frequently confirmed at autopsy. 

In many fractures of the skull extending into the orbital, temporal and 
occipital bones, the escape of cerebrospinal fluid may be so free that the 
tissues about the orbits, ears and in the occipital region will become mark- 
edly edematous and boggy. A mere ecchymosis of the orbit is, however, 
of no diagnostic value, since any injury to the anterior portion of the scalp 
will produce the typical "black eye." 

An ecchymosis of the scalp itself does not indicate the presence of an 
underlying fracture of the vault; but if the oozing of blood is subperi- 
cranial, then an underlying or adjacent fracture is very probable. Particu- 
larly is this true if the ecchymosis is in the temporal muscle beneath the 
temporal fascia, and especially if the overlying scalp is normal in appear- 
ance. In these patients the presence of an ecchymosis or free blood in the 
temporal muscle beneath the temporal fascia indicates the presence of a 
fracture of the underlying squamous bone most frequently, or of any 
part of the vault included within the limits of the attachment of the tem- 
poral muscle. This observation has been repeatedly confirmed, in 61 patients 
in all, both at the operation of cranial decompression in the subtemporal 
region and also in the other cases at autopsy. Careful bimanual examination 
of this temporal area will often reveal a sort of crepitus and indefinite 
"crackling," due to the digital compression of the free blood enclosed in 
the temporal muscle by the intact temporal fascia. A rontgenogram is of 
great assistance in confirming this diagnosis, which is of importance Owing 
to the frequent complication in these patients of the adjacent middle 
meningeal artery and the formation of a resulting extradural clot of varying 
size and compressive effect upon the underlying cerebral cortex. These 
fractures of the squamous bone, fortunately, extend very often into the 
middle ear, and, as the tympanic, membrane is usually ruptured, the 
intracranial hemorrhage can escape through the external auditory canal. 



20 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




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THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 21 

and so lessen the intracranial pressure. After the bleeding- has ceased 
careful otoscopic examinations should be made to ascertain the presence 
of a laceration of the tympanic membrane, as it is possible for profuse 
bleeding to occur from the ear, due to a small laceration of the wall of 
the external auditory canal itself and of little or no significance. Natur- 




Fig. 6. — Harriet G. This patient of 43 years of age slipped and fell headlong from the front door- 
steps to the pavement — a distance of four feet; no loss of consciousness — "merely dazed. " and that after- 
noon, she came to the out-patient department of the hospital by trolley-car on account of the "bump" 
over her forehead, which was gradually enlarging, and "a dull aching in the head." The hematoma was so 
tense and extensive that palpation and the routine bimanual examination, in the presence of her hair. 
were negative. She was permitted to return to her home and advised to "come for an X-ray picture i.i the 
morning." The huge depressed fracture of the vault, and the radiating linear fracture to the base, wore 
most instructive, and fortunately in this patient an excellent result was obtained by performing a right 
subtemporal decompression, first to lower the general increased intracranial pressure of blood-tinged 
cerebrospinal fluid, and then the local depressed area of bone was removed; the underlying dura had been 
lacerated and even some cerebral tissue was lying at the site of the depression. The present condition of 
the patient, thirty-four months after the injury, is normal. The value, however, of an early rontgeno- 
gram in this type of patient is obvious. 

ally, if cerebrospinal fluid is discharged from the ear it indicates the presence 
of a fracture of the skull into the middle ear. 

Rontgen Rays. — Roentgenograms in cranial injuries are o( groat value 
in the accurate diagnosis of fractures of the skull, but it is only in occasional 
patients having brain injuries that X-ray pictures are of any great aid 
in the treatment of these patients. Naturally, questionable depressed t'rae- 



22 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tures of the vault should always be pictured, and I believe that all cranial 
injuries of any severity, and in many cases of even mild degree, should 
have a rontgenogram taken in two or more planes for fear a trivial ' ' bump ' ' 
may be of greater severity than the history might indicate, and thus the 
appropriate careful treatment be neglected, or at least delayed (Fig. 6). 
But to insist in the more serious traumatic conditions of acute intracranial 
lesions that an X-ray picture be taken, even if such a procedure should 
delay and even postpone the operative treatment of the condition, such 
as ' ' waiting overnight ' ' in order to have a picture taken, is, in my opinion, 
not only poor judgment but an absurd and dangerous attitude. The sooner 
it is generally realized that the treatment in brain injuries (excluding 
depressed fractures of the vault) is not directed so much toward the ascer- 
taining of the presence or not of a skull fracture, and its location and 
extent, as toward the lessening of the effects of the cranial trauma upon the 
intracranial contents — whether there is a fracture or not — just so much 
sooner will these patients receive a rational treatment. The mere fact that 
there is a fracture or "crack" in the skull, as shown by the rontgenogram, 
is no reason to advise an operative procedure, and, conversely, the absence 
of any definite fracture being revealed by the X-ray is no reason that an 
operation to lessen the intracranial pressure due to hemorrhage or edema 
may not be necessary. 

Linear fractures of the vault occur much more frequently than is 
commonly believed and recognized. Routine rontgenograms are now taken 
of all my patients who have had a "bump" upon the head — at least two 
views: antero-posterior and lateral — and it is surprising the number of 
latent fractures of the vault which are thus disclosed. The effect may 
be of a trivial character, and yet when we know that a fracture of the vault 
is present, the examination and treatment of such a patient are undoubtedly 
more careful, and the prognosis is more guarded. Many of these patients 
have walked into the accident room of the various hospitals, the scalp not 
even being lacerated, and have complained merely of the "bump" and a 
slight headache ; the latter might not continue longer than three or four days 
under the routine expectant palliative treatment. The usual sites for these 
latent fractures of the skull are the squamous portions of either temporal 
bone and the greater wings of the sphenoid bone posterior to the external 
angular process of the orbit (Fig. 7). Both sides of the head should be 
exposed, Stereoscopic views are very helpful. 

The interpretation of rontgenograms of basal fractures is very baffling, 
and it is frequently impossible even to secure satisfactory pictures. The 
bony irregularities of the base of the skull, and the difficult position neces- 
sary to obtain the proper plane in order to facilitate the exposure of the 
fracture — these factors make the X-ray pictures of very doubtful value. 
A negative picture does not by any means indicate that a fracture does not 
exist. Fractures about the foramen magnum may be better photographed 
at times through the open mouth. 

Naturally, the treatment of these patients remains the same, whether 
there is a fracture or not, a decompression being considered only in the 
presence of marked intracranial pressure. The operation is not to remedy 






THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 23 




Fig. 7. — James E. When this man of forty-nine years of age was found lying in a hallway by a 
policeman as if in a drunken stupor, he was helped to the station-house where he remained all night in a 
cell to be arraigned for "drunkenness" in the morning. Not having recovered consciousness sufficiently 
to be tried before the magistrate, the man was transferred in the patrol wagon to the hospital, where he 
died two hours later from an acute medullary edema. The autopsy revealed two lines of fracture of the 
base of the skull — an irregular oblique one in the left greater wing of the sphenoid bone and another one 
along the crest of the left petrous bone but not into the middle ear; the left tympanic membrane was not 
ruptured — therefore, no bleeding or discharge of cerebrospinal fluid from the left ear. The brain itself 
was very "wet" and edematous with much free blood subtentorially about the medulla. Intracranial 
injuries are commonly obscured and concealed by alcoholism, and the most careful examinations are 
necessary to differentiate these conditions early — in order to be of value to the patient. 

the fracture (unless it be a depressed fracture of the vault), but to otYset 
the results of the fracture and the injury to the brain. In my opinion, all 
patients having- possible brain injuries should be treated by the expectant 
palliative method, whether a fracture of the skull is present or not, and a 
decompression advised only when this method tails to prevent an increasing 
intracranial pressure, as shown by the careful and repeated neurological 



24 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

examinations, especially the use of the ophthalmoscope, and confirmed by a 
measurement of the pressure of the cerebrospinal fluid at lumbar puncture 
by means of the spinal mercurial manometer. 

Fractures of the occipital bone, subtentorially and radiating downward 
to the foramen magnum and even beyond, along the basilar process, are 
the most serious of all cranial fractures. The great danger of direct pressure 





Fig. 8. — Esther R. This patient of twenty-four years of age fell while skating upon the ice, striking 
the back of her head. No immediate loss of consciousness; was able to walk home and to eat at the dinner 
table in spite of a "-dull headache." Vomiting occurred two hours later, and at three o'clock (six hours 
after the injury), it was found that she could not be aroused to consciousness; her pulse was then fifty-four 
and respirations twelve and of a Cheyne-Stokes character. Upon admission to the hospital one hour later, 
an X-ray picture revealed a narrow linear fracture extending vertically downward and backward from the 
right parietal bone through the right half of the occipital bone into the right margin of the foramen magnum. 
The condition of the patient quickly changed after admission to the hospital in that the signs of medullary 
compression merged into those of an acute medullary edema — a rapidly ascending pulse- and respiration- 
rate, so that the patient was in extremis before the preparations for the operation of suboccipital decom- 
pression could be made. The autopsy revealed a large subtentorial hemorrhage directly compressing the 
medulla. An earlier operation would have afforded this patient a definite chance of recovery; the delay 
necessitated by an X-ray picture was inexcusable. 



upon the medulla itself, due to any resulting hemorrhage or edema sub- 
tentorially, is the complication most to be feared, and the one that usually 
terminates fatally within several hours unless it is of very mild degree 
(Fig. 8). 

Fractures extending into the nose, mouth or ears, so that the escape 
through them of intracranial hemorrhage and cerebrospinal fluid is possi- 
ble, frequently facilitate the expectant palliative treatment by permitting 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 25 

any increase of the intracranial pressure to be lowered by this means of 
drainage — a sort of "natural" decompression; the danger of infection 
extending intracranially through this line of fracture, and thus producing 
a purulent meningitis and meningoencephalitis, is a slight one, unless 
meddlesome procedures are used, such as attempts to "swab" and "clean 
out" and theoretically sterilize the auditory canal and nares, and in this, 
manner infective organisms are introduced through the line of fracture. 
The "snuffing" of aseptic solutions into the nose, and the irrigation of the 
ears of these patients, cannot be too strongly condemned. Moist aseptic 
gauze pads, loosely placed over the nares, so that the patient breathes 
chiefly through the mouth, and a similar gauze pad over the lobe of the ear, 
and not so tightly as to block the aural discharge, usually suffice to lessen 
the danger of a possible infection. In this series of patients having cranial 
fractures which extended into the nose, mouth or ears, a resulting infection 
occurred in only 4.6 per cent, of them (Fig. 9). The use of urotropin 
internally is nO longer advocated, since it has been determined that urotropin 
is only effective in acid media, such as the urine, and not in neutral or 
alkaline media, such as the cerebrospinal fluid. 

The most extensive linear fractures of the skull occur in children, and 
frequently with little or no apparent damage to the enclosed brain. So 
much drainage of the intracranial hemorrhage and increased cerebrospinal 
fluid into the nose, ears and tissues of the scalp and neck, is thus afforded in 
so many of these patients that they really ' ' decompress ' ' themselves, and so 
an excellent recovery is obtained without the necessity of a cranial operation. 

B. General Signs. — 1. Shock. — It is infrequent for cranial injuries to 
occur and not be associated with more or less shock, while it is most rare for 
brain injuries of any severity to exist without there being present the initial 
complication of shock. Only too frequently the condition of initial shock 
in these latter cases is so extreme that the patient is unable to survive it, 
and an early death results from the shock alone. These fatal cases of 
traumatic shock may occur irom any severe bodily injury, and particularly 
of the abdomen and chest, and yet it is in brain injuries that the condition 
of initial shock is of the greatest importance and danger. If the patient, 
following a cranial injury, is in a severe state of shock, then all efforts 
should be directed toward the overcoming of the shock — no prolonged 
neurological examinations made, but the immediate use of measures to 
combat the shock, such as external warmth to the body (heated blankets. 
hot-water bottles, etc.), repeated rectal enemata of hot black coffee, absolute 
quiet, and codeine or morphine, if necessary, for restlessness. In this 
severe condition of initial shock, the chief concern of the physician is not 
whether a definite brain injury or a fracture of the skull is present or not. or 
whether there is a facial paralysis or a Babinski reflex present or not. or 
whether there is a depressed fracture of the skull or bleeding from the ear 
through a ruptured tympanic membrane, and many other data and obser- 
vations of value later to both the patient and the doctor, but rather the 
early recognition of the severity of the shock and the appropriate treatment 
immediately instituted and then — the patient "'let alone" until the condition 
of initial shock is survived, no matter how badly the skull is fractured, how 



26 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

pronounced the hemiplegia may be, or how ' ' typical ' ' the double Babinski 
may appear. If the patient cannot survive the shock, it will be of no value 




. Fig. 9. — Patrick K. Multiple radiating linear fractures of the vault extending forward into both 
orbital plates and nares, in a youth of eighteen years of age, who had been struck by an automobile; only 
a momentary loss of consciousness. Profuse and continued nose-bleed for three hours; a "watery fluid" 
flowed out of the nose in spurts about every fifteen minutes. "In order to stop the bleeding from the 
nose, " a weak solution of adrenalin was "snuffed" up into the nose and adrenalin gauze packing inserted. 
Following this meddlesome treatment, and three hours after the injury, the patient was brought to the 
hospital in the ambulance; the expectant palliative treatment alone was indicated and the patient was 
making such an excellent recovery that he was permitted to sit out of bed on the sixth day after the injury. 
On the eighth day, however, the patient suddenly had a general convulsive seizure and remained uncon- 
scious; the temperature ascended to 104.8 and a lumbar puncture removed cloudy cerebrospinal fluid 
containing numerous streptococci, so that no cranial operation for drainage was advisable. An autopsy, 
twenty hours later, confirmed the rontgenograms and disclosed a purulent meningitis and meningo- 
encephalitis of both frontal lobes; much free pus (streptococci and staphylococci) was found about the 
fractures of the cribriform plate of the frontal bone — the channel for the infection. 



or interest to him whether the skull was fractured or net, or whether 
Babinski reflex was present or not. 

These patients in shock may or may not be unconscious. A cold, clammy 
skin, with pallor of greater or less degree, is usually present; a subnormal 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 27 

temperature ; the pulse-rate is usually 130 plus, being of a weak, thready, and 
irregular character in the severe cases, while the respiration-rate is between 
30 and 40, shallow, and at times scarcely perceptible ; the blood-pressure 
may be 100 — rarely below (Fig. 10). This period of severe initial shock 





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Fig. 10. — No. 624. — Alice, eighteen years. Clinical chart presenting the typical temperature, pulse 
and respiration syndrome of an uncomplicated condition of shock following a cranial injury with multiple 
fractures of the vault and base of the skull. Uneventful recovery from the shock within six hours, and as do 
signs of a marked increase of the intracranial pressure were then disclosed by the ophthalmoscope and 
the spinal mercurial manometer (although the cerebrospinal fluid was blood-tinged), this patient could be 
discharged from the hospital on the eighth day after the injury. Last examination (September 6, 1919) — 
twenty-tour months after the cranial injury: no complaints; physical examination — negative. 



rarely lasts longer than 12 hours ; usually it is about 6 hours after the cranial 
injury before the patient shows definite signs of improvement: a lowering 
of the pulse- and respiration-rates, while the temperature and blood-pressure 
rise. If the patient is unable to survive an extreme condition of shock, then 
an early pulmonary edema occurs — moist rales throughout both lungs, and 
the patient quickly succumbs — within 24 hours, and usually within 6 hours 
after the injury. 

The condition of severe shock can usually be differentiated from that 



28 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

of the terminal stage of medullar}' edema and collapse by the clinical history 
and the temperature chart. In these patients of medullary edema, the pulse- 
and respiration-rates have been low for a period of minutes, and even hours, 
following the cranial injury — that is, the signs of medullary compression — 
and then, after the lowest level of the pulse- and respiration-rates for the 
patient has been reached, such as 46 and 12 respectively, there is a rapid 
rise, so that within two hours the pulse may be 70 and the respiration 24, 
and within six hours the pulse 110 and the respiration 30, and two hours 
later even 140 and 40 respectively, and at the same time the temperature 
quickly rises to 105 and above, while the blood-pressure descends to 110 
and lower — the condition of medullary edema, and not of shock or delayed 
shock, has now unquestionably occurred. Medullary edema and collapse is 
the bane of brain lesions, traumatic and otherwise, and it cannot be feared 
too much, since it is always the forerunner of death in these patients. In the 
most extreme cases, and particularly in the subtentorial lesions, the condition 
of medullary edema may occur within a few minutes after the cranial injury, 
and the patient be dead before a competent examination in a hospital is 
possible ; it is in these patients that a post-mortem examination is essential, 
in order to state whether extreme shock or medullary collapse was the 
immediate cause of death. 

2. Temperature. — As an index of the general condition of the patient 
following a cranial injury, the temperature is helpful, and especially so 
during the two extreme and most dangerous periods — the period of initial 
shock, when the temperature is subnormal, and then the terminal stage 
of acute medullary edema, when the temperature ascends rapidly to 105 and 
higher. Naturally, the other clinical signs should be considered with the 
temperature, but together they form a picture which is usually a most 
characteristic and typical one of the period in which the patient having 
a brain injury happens to be. It is extremely rare for these patients to have 
a normal temperature, and, if the condition of shock is excluded, there is 
almost always a temperature of 100 to 102, varying as the condition of the 
patient changes. Temperature in itself, however, is no indication of the 
degree of intracranial pressure, unless a medullary edema has been produced 
— and then it is too late to utilize the temperature findings in the treatment 
of the patient, as these patients in medullary edema ail die, treatment or no 
treatment. Injuries of the base of the brain and supposedly "upsetting'' 
the basal ganglia would cause an early rise of temperature, and are not 
necessarily associated with the other clinical signs of cerebral injury. 

3. Pulse. — Owing to the usual presence of shock of varying degree, the 
pulse-rate following a brain injury is frequently 120 and higher, and this 
may continue for several hours, until the shock gradually disappears ; the 
pulse will then become lowered to its normal rate, and may become much less ; 
if it should reach 60 or lower, a definite degree of intracranial pressure is 
usually present. However, the normal pulse-rate of the patient before the 
injury should, if possible, always be ascertained. The pulse-rate, unfor- 
tunately, is not an accurate or an early means of determining the severity 
of the intracranial lesion ; ordinarily, the greater the intracranial pressure 
and, therefore, the less the blood supply to the medulla, the slower the 
pulse-rate ; but the resistance of the medulla to slight changes in its circula- 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 29 

tion varies so much in different individuals that it is possible to have a high 
degree of intracranial pressure and yet a pulse-rate remaining between 
70 and 80 for a period of hours. Finally, the regulatory mechanism of 
the medulla may become affected, and then the signs of medullary compres- 
sion advance unusually rapidly, leading to the quick death of the patient. 
I have had several patients in whom the pulse-rate remained between 70 and 
80, and yet the ophthalmoscope revealed marked signs of high intracranial 
pressure ; at operation, the high pressure was confirmed, being usually due 
to a markedly swollen edematous brain, with numerous punctate hemor- 
rhages in its cortex and the subdural cerebrospinal fluid being blood-tinged. 

If the pulse-rate, however, becomes lowered to 60, and especially to 50, 
we have an excellent though rather late danger signal, which should always 
be heeded as an evidence of medullary compression (Fig. 11). Any further 
lowering of the pulse-rate is usually associated with an irregular respira- 
tion-rate of the Cheyne-Stokes type, and then the prognosis becomes very 
poor indeed. 

As the pulse-rate descends, the character of the pulse itself becomes full, 
strong, and well sustained — apparently an excellent pulse. It is, however, 
only the attempt of the circulatory mechanism to overcome the partial 
anemia of the medulla, due to the increased intracranial pressure, and thus 
to force blood into it. If this condition remains for a variable length of time, 
signs of medullary edema and finally collapse — rapid, shallow pulse, and 
quick, irregular respirations — may occur at any moment, and then death is 
merely a matter of hours. 

Many of the most severely injured and moribund patients, even at the 
first examination within one hour after the head injury, have a pulse-rate 
over 120, either of pure shock or of shock associated with the early stages 
of medullary edema. If the rapid and shallow pulse-rate, associated with 
a subnormal temperature, is due simply to shock, then there is a definite 
chance of recovery, as shown by the gradual disappearance of the signs 
of shock and the lowering of the pulse-rate ; if, on the contrary, medullary 
edema is progressing, then, together with the elevated temperature, the 
pulse-rate remains high and gradually ascends until it is no longer obtain- 
able before the death of the patient. Naturally, all of these patients should 
be treated expectantly and for the condition of shock, in the hope that the 
medullary edema is only a temporary complication. It must be admitted, 
however, that once a true medullary edema does occur, then the pulse-rate 
rapidly ascends, becomes more and more shallow, and I have yet to see such 
a patient recover. Any operative procedure at this stage of extreme shock 
and medullary edema and collapse merely hastens the exitus of the patient. 

4. Respiration. — The respiration, like the pulse-rate, is affected by shock. 
and may exceed 40 for an hour or more immediately after the injury: its 
rate, however, becomes the normal 20 to 24 much more quickly, and remains 
normal unless the intracranial pressure becomes so high as to cause the 
definite medullary signs of a Cheyne-Stokes type of breathing. In these 
patients, the "period of apnea or non-breathing may exceed 40 seconds. It 
seems that the pulse is more easily affected by intracranial pressure than the 
respiration, and when the latter is influenced a medullary edema and 
collapse may occur at any moment (Fig. V2) . 



3 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

An early medullary edema of rapid onset, and associated or not with 
severe shock, may prevent the respiration-rate, just as it does the pulse-rate, 
from being lowered, so that from the time of the first examination imme- 
diately after the cranial injury until the death of the patient, the respiration 
is continuously shallow and of a rate higher than 40. These are the so-called 



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Fig. 11. — No. 312. — William, forty-two years. Clinical chart representing the rapid onset of acute 
medullary compression within three hours following a severe cranial injury but not associated with a frac- 
ture of the skull. Signs of an increasing intracranial pressure were also disclosed by the ophthalmoscope 
and the spinal mercurial manometer, although the cerebrospinal fluid at lumbar puncture was clear. At 
the operation of right subtemporal decompression, a "wet" edematous cortex was revealed under high 
pressure, so that upon incising the dura the clear cerebrospinal fluid spurted to a height of ten inches; no 
hemorrhage observed. Uneventful recovery. Last examination (December 14, 1918) — nineteen months 
after injury: no complaints; physical examination — negative. 

moribund patients, who die usually within six hours after the injury. In 
many of these patients the brain injury is associated with internal injuries 
of the abdomen and of the chest and thus lessening still more the chances of 
recovery. The usual presence, however, of an extreme degree of shock 
these patients always makes the vigorous treatment of the shock 



in 



most imperative. 

5. Blood-pressure. — It 



has been most interesting in patients having 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 31 

brain injuries to record the influence of intracranial pressure upon the 
general blood-pressure. It was surprising to ascertain that rarely was the 
blood-pressure forced beyond 160, and then only in the patients showing 
early signs of medullary compression ; in these patients the blood-pressure 
might ascend to 200, with a pulse-rate of 50 and below, and a Cheyne- 



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Fig. 12. — No. 892. — Arthur. Clinical chart illustrating the temperature, pulse and respiration 
syndrome of the stage of medullary compression merging into that of acute medullary edema with the 
usual result — the death of the patient. Upon admission to the hospital, the fundi were negative but the spinal 
mercurial manometer registered a pressure of 20mm.; while waiting for the operating room to be prepared, 
the temperature, pulse- and respiration-rates began to ascend rapidly within one hour after admission to 
the hospital, showing that the stage of medullary compression had advanced into that of medullary edema, 
and therefore it was too late to perform the operation of cranial decompression in order to be of benefit 
to the patient. The autopsy revealed a subdural hemorrhage with extreme cerebral edema, but no frac- 
ture of the skull. 

Stokes respiration, showing an extreme degree of intracranial pressure and 
one that could not be long sustained by the medulla. These were the 
patients allowed to wait a number of hours before the operation of cranial 
decompression was performed, and their recovery was most doubtful. The 
operative mortality is very high for patients that have been allowed to 
reach this extreme degree of medullary compression; signs o\' a medullary 
edema and collapse — high pnlse-rate of a shallow, poorly sustained char- 



32 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

acter, irregular shallow respirations, and a blood-pressure of 100 and 
even less — usually followed within several hours until death, operation 
or no operation. 

A number of years ago, venesection was considered advisable to lower 
this increase of the general blood-pressure associated with medullary- com- 
pression; von Bergman and Leonard Hill thought favorably of it. How- 
ever, it is no longer employed, because it is now known that this increase in 
the general blood-pressure is the attempt of the natural vasomotor mechan- 
ism to force blood into the intracranial chambers, and thus into the medulla, 
by overcoming the increased intracranial pressure. To bleed a patient, 
therefore, even in the very mild cases, is an exceedingly dangerous procedure, 
of no real value, and is always contraindicated. 

At best, the general blood-pressure is a very crude method of estimating 
the intracranial status of pressure. Besides, the factor of initial shock, 
which is almost always present in varying degree for several hours at least, 
tends to conceal the true intracranial condition. The high intracranial 
pressure necessary to raise the general blood-pressure to any appreciable 
extent must reach a very dangerous stage of compression in these acute 
cases before its effects can be observed in an increased blood-pressure. Par- 
ticularly is this true of a cerebral and supratentorial increase of pressure, 
whereas a cerebellar and subtentorial increase of pressure produces an 
almost immediate rise in the blood-pressure. Naturally, these latter con- 
ditions are most serious ones, and rarely do these patients survive, operation 
or no operation. I feel, therefore, that the blood-pressure as an important 
aid in the treatment of brain injuries has been very much overemphasized. 
I have had the blood-pressure ascertained in all of my patients, but it has 
rarely been of any material assistance as an indication of the status of the 
patient, except as an additional diagnostic aid in the subtentorial lesions. 
It should be remembered that brain injuries are acute conditions associated 
always with shock, whereas brain tumors are usually of slow growth, and 
not associated with the masking factor of shock. It has been a most interest- 
ing study to observe the rhythmical variations of blood-pressure synchronous 
with the variations of temperature, pulse- and respiration-rate, a lowered 
Wood-pressure (100-120) during the period of initial shock, associated with 
a subnormal temperature and increased pulse- and respiration-rate. As the 
shock lessened, then the blood-pressure slowly ascended (130-140) with the 
temperature, while the pulse- and respiration-rate descended. If the intra- 
cranial pressure became very high, then the blood-pressure continued to 
ascend slowly (140-160), the temperature remaining above normal (101- 
103), and the pulse- and respiration-rate dropped to 60 and 16, respectively, 
and even lower. If medullary edema should be permitted to occur, then 
the blood-pressure descended rapidly to 100, and even lower, while the 
temperature rose to 105 plus, and the pulse- and respiration-rate to 150 
and 40 plus, respectively, to be followed within several hours by the exitus 
of the patient. 

6. Paralysis. — The condition of central or cortical paralysis, and usually 
only a paresis or weakness of the extremities, does not in itself indicate 
the necessity of a cranial operation. If there are no marked signs of in- 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 33 

creased intracranial pressure, and a depressed fracture of the skull cannot 
be ascertained, then the expectant palliative treatment should be used in 
the belief that the paralysis is only of temporary duration, and therefore 
due to localized edema of the motor cortex with or without being associated 
with a small laceration of the adjacent cortex. If the definite signs of an 
increased intracranial pressure appear, or the paralysis continues for a 
period of days, then an exploratory decompression and drainage would be 
indicated over the hemisphere involved. Naturally, a large cortical lacera- 
tion through either motor area means a permanent damage to the cells 
destroyed, there being no cell regeneration possible ; but there is always 
associated with these extensive lacerations and contusions of the cerebral 
cortex a profuse localized cerebral edema, so that the cortical nerve cells 
surrounding the lacerations are merely compressed and functionally im- 
paired by the edema, which is usually of such an amount as to increase the 
intracranial pressure. Therefore, in these patients, as a result of the 
signs of this increased intracranial, pressure, the operation of subtemporal 
decompression and drainage is advisable, and thus an early recovery of 
function of the paralyzed extremities is facilitated. The milder degrees 
of cortical laceration and localized edema do not produce the definite signs 
of a marked increase of the intracranial pressure, and therefore no cranial 
operation is necessary, the natural means of absorption alone being sufficient. 

Unless the fracture of the skull is a depressed one, over either motor 
tract, so that the underlying cortex is compressed, and even lacerated, or 
there is a large extradural hemorrhage (due to a rupture of the middle 
meningeal artery), and, less frequently, a subdural clot overlying the same 
area, or a general or localized edema of the motor area, with or without 
a definite cortical laceration, it is rare for a fracture of the skull to produce 
paralysis of the extremities ; especially is this true of fractures of the base. 

Paralyses of the cranial nerves and particularly those controlling the 
movements of the eyeball — the third (oculi motorius), the fourth (pathe- 
ticus), and the sixth (abducens), and also of the seventh (facialis) — are 
fairly common in basal fractures, resulting in ptosis, strabismus, and facial 
paralysis. If the nerves have been severed, then a permanent paralysis 
results, but most frequently the paralysis is of temporary duration only, and 
it fades away after the local pressure of hemorrhage or edema has been 
removed by absorption; this is particularly true of the facial nerve in its 
narrow bony canal in the aqueduct of Fallopius — its edematous compression 
producing the peripheral type of facial paralysis. The other cranial nerves 
occasionally affected are the first (olfactorius), the fifth (trigeminus), and. 
more frequently, the eighth (auditorius). The second (opticus) and the 
other cranial nerves are rarely primarily affected. 

A temporary motor aphasia frequently results from a subdural and 
supracortical hemorrhage overlying the motor speech area, and from 
a partial laceration of the cortex adjacent to the left third frontal con- 
volution posteriorly ; it is usually merely a paraphasia, a pure motor aphasia 
being most rare. 

The absence of paralysis, therefore, is of little significance o\' the serious- 
ness of brain injuries. The advisability of an operation or not is rarely 
3 



34 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

dependent upon the presence or the absence of paralysis. In many patients, 
and possibly the majority of those having cortical paralyses, the paralysis is 
due to a localized edema, or even a definite laceration of the motor cortex 
itself — not a complete destruction of it, but a partial tear, and associated 
with the resultant cortical edema; thus, a sufficient cause for a distinct 
paralysis of the hemiplegic type, with or without a marked increase of the 
intracranial pressure. It is rare for the hemiparesis to be a permanent one, 
on account of the absorption of the cerebral edema about the cortical 
laceration, which extends throughout the motor tracts in only very infre- 
quent cases. Naturally, no operation would be indicated for a laceration 
of the brain unless it was associated with a definite increase of intracranial 
pressure, which may or may not be present. The frequent statement, there- 
fore, that paralysis is an indication for operative interference in brain injur- 
ies cannot be credited. If there is no increased intracranial pressure, due 
to hemorrhage or to cerebral edema, surely no operation will be of any 
assistance to the patient. 

The great frequency of cortical lacerations and contusions of the " con- 
tre-coup" type is very impressive. The anterior and inferior surfaces of 
the frontal lobes are usually the areas affected, due undoubtedly to the direct 
contact of the cranial trauma being usually in the region of the posterior- 
occipital bone. The tips of the temporo-sphenoidal lobes are lacerated by 
" contre-coup" next in the order of frequency. As both the frontal and 
the temporo-sphenoidal lobes are comparatively ' ' silent ' ' areas of the brain, 
it will thus be seen that the condition is rarely diagnosed ; besides, the treat- 
ment remains the same, laceration or no laceration of the cerebral cortex. 

In this connection, the possibility of a laceration of the pyramidal tract 
fibres in their course from the cortex down through the internal capsule to 
the pons and medulla should be remembered ; fortunately this complication 
rarely occurs, and the same may be said regarding an active hemorrhage into 
the ventricles and internal capsules following cranial trauma, and thus pro- 
ducing pyramidal tract compression ; their possibility in elderly patients 
is theoretically always to be feared. The expectant palliative treatment 
would here be indicated, although in an acute traumatic ventricular 
hemorrhage of sufficient size to produce an increased intracranial pressure, 
an early subtemporal decompression, with drainage of the ventricle, might 
be indicated in selected patients ; I have operated upon four patients, with 
two recoveries. 

7. Impaired Sensation. — It is rare for areas of hypesthesia and anes- 
thesia to be present, and most rare for areas of hyperesthesia to exist in 
these traumatic cranial patients. They do occur, however, if a large extra- 
dural or subdural hemorrhage exerts a pressure over the post-Rolandie cor- 
tical area sufficient to lessen its sensitiveness to afferent impulses. Usually, 
however, merely a mild hypesthesia results; an astereo2'nosis may or may 
not be present. This cortical impairment of sensation of one-half of the body 
is usually associated with a definite hemiplegia of the same side, on account 
of the extension of the hemorrhagic clot forward beyond the fissure of 
Rolando, and thus over the motor area. Subcortical lacerations or hemor- 
rhage may affect the afferent sensory pyramidal tract fibres just as they 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 35 

do the efferent motor fibres of these tracts, and the comment is the same 
as in the preceding paragraph upon paralysis. Traumatic lesions of the 
internal capsular fibres rarely occur without the definite association of motor 
and sensory impairments of the opposite side of the body, similar to apoplexy 
of the internal capsular type (the usual form) . Hypesthesia and even anes- 
thesia of the ipsolateral half of the face may result from compression or 
direct injury to the fifth cranial nerve (trigeminus or trifacial) ; rarely 
is this impairment a permanent one, being usually due to an edema of the 
nerve itself, following a fracture of the adjacent portion of the petrous bone. 

8. Unconsciousness. — Prolonged total loss of consciousness in patients 
having brain injuries, with or without a fracture of the skull, usually indi- 
cates a high degree of intracranial pressure, due to hemorrhage or edema, 
or an extensive laceration and destruction of the brain substance itself, 
with comparatively small amount of associated hemorrhage and edema. 
Loss of consciousness, however, is not necessarily associated with a high 
intracranial pressure, nor does a high intracranial pressure always produce 
a loss of consciousness. Some of the patients in this series of brain injuries, 
having the highest intracranial pressure (sufficient to produce the early 
signs of a beginning medullary compression), were called only "unusually 
drowsy" and "stuporous," and were easily aroused by supra-orbital pres- 
sure, by pricking the skin, or even by calling the patient's name. 

In cases of slowly progressing hemorrhage and of edema intracranially, 
as revealed by the ophthalmoscope, lumbar puncture and confirmed by 
operation, the various stages of "feeling of tiredness," then drowsiness, 
stupor, coma, and finally total unconsciousness, may be observed within a 
period of several hours. It is not a very unusual occurrence to have such 
patients walk into the hospital with the complaint of "throbbing" in the 
head, and then pass gradually through these stages to total unconsciousness. 
The vast majority of patients, however, following a brain injury, with or 
without a fracture of the skull, are more or less comatose, and it is of the 
greatest importance to observe whether the degree of coma lessens or 
increases, according to variations of the intracranial pressure. 

9. Restlessness. — Instead of being drowsy and stuporous, a large number 
of the patients having brain injuries, with or without a fracture of the 
skull, are in the irritative stage of the condition — that is, owing to the sud- 
den oozing of supracortical blood and to the edema of the cerebral cortex 
itself, immediately following the brain injury, there is a definite irritation 
of the underlying cerebral cortex — merely a lessened emotional control in 
the very mild cases, to the extreme degrees of restlessness, mental excite- 
ment, and even acute mania in the more severe cases. Naturally, this violent 
"threshing about" in the bed and the vigorous muscular exertions should 
be prevented by every means possible, as the danger of increasing the intra- 
cranial lesion of hemorrhage and edema is very great. Besides the routine 
application of the ice helmet (surrounding the entire head and strapped to 
the head), triple bromides and chloral in large doses should be given ; morphia 
is frequently effective. Since the adoption of the routine use of the ophthal- 
moscope and of the spinal mercurial manometer for estimating the intra- 
cranial pressure, there is little or no danger of morphia masking the true 



36 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

intracranial condition. Formerly, it was advisable to restrict the adminis- 
tration of morphia, for fear that the intracranial condition might be con- 
cealed, and the proper treatment thereby so delayed until the condition of 
the patient became most serious. This was perfectly true formerly, but since 
it has become more and more recognized that no cranial operation is indicated 
in these patients unless there are definite signs of an increased intracranial 
^pressure (as can very easily be determined by the ophthalmoscope and by 
the spinal mercurial manometer), there should be no longer any hesitancy 
in administering morphia in sufficient quantity to control the patient. 

10. Convulsive Seizures. — Spasmodic twitchings, and even convulsions, 
usually of the localized Jacksonian type, occur very frequently as the result 
of an acute cortical irritation, due to the presence of subarachnoid and 
subpial (cortical) hemorrhages and edema; occasionally subdural clots 
produce them, as confirmed by operation. Convulsive seizures are very 
infrequent in the other forms of intracranial pressure and hemorrhage. 
Acute depressed fractures of the vault rarely cause sufficient cortical irrita- 
tion to produce convulsions until months, and even years, later, and then 
only when associated with a chronic cerebral edema to the extent of increas- 
ing the intracranial pressure. 

The comparative infrequency of convulsions associated with acute brain 
injuries is very singular. In this series of 487 patients having acute brain 
injuries, in only 27 of them were convulsions or even localized twitchings to 
be observed. At the operations upon 155 of these patients as well as at the 
autopsies upon the 69 non-operated patients who died, the presence of sub- 
dural and, cortical hemorrhage and of cortical edema was very frequently 
demonstrated as a possible cause of convulsive seizures and twitchings, and 
yet convulsions rarely occurred. Possibly the cortical nerve cells in these 
acute cases were less sensitive to local irritation, being "benumbed," as it 
were, by the shock and acute cerebral edema, and thus the ' ' explosive ' ' reac- 
tion producing convulsions was inhibited — merely a theoretical explanation. 

Just why a small number of these patients develop epilepsy later is, in 
my opinion, not so much a question of possible cortical adhesions, depressions 
of the vault or foreign body spicules, but, rather, in addition to these factors, 
a condition depending upon the permanency of the cerebral edema producing 
a chronic increase of the intracranial pressure, and especially in patients of 
lessened stability nervously. I have examined a large number of these 
post-traumatic epileptics, some of them having had but two or three convul- 
sive seizures, and yet they all had chronic "wet," swollen, edematous brains, 
causing a definite increase of the intracranial pressure. Many of these 
patients did not have* cortical adhesions, to be disclosed either at operation 
or at autopsy. In this connection, it must always be remembered that fre- 
quent convulsions will eventually produce a "wet" edematous condition of 
the brain, so that any increase of the intracranial pressure in many of the 
chronic patients is a secondary one, resulting from the convulsions rather 
than being the primary cause of the convulsions. A method of determining 
whether the increased intracranial pressure in these post-traumatic epileptics 
is primary or secondary to the convulsions, is to ascertain the pressure of 
the cerebrospinal fluid at lumbar puncture by means of the spinal mercurial 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 37 

manometer, then by the vigorous use of triple bromides, luminal, etc., to 
prevent the convulsive seizures from occurring for a period of at least one 
month, and, better, six weeks. If the pressure as registered by the spinal 
mercurial manometer is practically the same as at the preceding examination 
immediately following the last convulsion, then the increased intracranial 
pressure is primary as concerns the convulsive seizures; whereas, if the 
measurement of the pressure of the cerebrospinal fluid is now markedly 
lowered to almost normal, then it may be concluded that the increased 
intracranial pressure is secondary to the convulsions — that is, the convulsions 
are causing the chronic cerebral edema, rather than the cerebral edema being 
a factor in producing the convulsions. This test is an important one in regard 
to the advisability of any operative procedure to relieve the increased intra- 
cranial pressure in these patients; and naturally no cranial operation of 
decompression can be considered for those patients in whom the increased 
intracranial pressure is secondary to the convulsions, and is therefore not 
one of the primary factors of the convulsions. To operate upon the former 
group of patients, in whom the intracranial pressure is secondary to the 
convulsions, and then to expect a subtemporal decompression to be of benefit, 
is absurd, and this neglect to differentiate these two types of post-traumatic 
epilepsies has in reality discredited cranial surgery in the treatment of 
selected cases of post-traumatic epilepsy. The surgical treatment of con- 
vulsive seizures in these patients is notoriously bad, and it will remain so 
unless greater care is used to ascertain which patients are amenable to opera- 
tive treatment — and only a very small percentage of them are ; and then, 
upon these early selected patients having a primary increased intracranial 
pressure, a simple subtemporal decompression will occasionally be of per- 
manent benefit. At best, however, the surgical treatment of these selected 
patients should only be used after the most careful study and consideration, 
and in only the very early cases. 

It would seem to be a fact that the brain cells of certain neurotic patients 
are more unstable than those cells of the more stable and phlegmatic types 
of patients, so that a less active cortical irritant is necessary to cause con- 
vulsions in the former class than in the latter class of patients. Alcohol, as 
a factor, must always be considered, because it increases the cortical irrita- 
bility, and renders the cells less stable ; it alone may even produce convul- 
sive twitchings and seizures. 

11. Reflexes. — The presence of shock in these acute cases is an important 
factor in influencing the activity of the superficial and deep reflexes ; in the 
mild degrees of shock, the skin-reflexes cannot be elicited while the deep 
reflexes are present, and in the extreme condition of shock they may both be 
entirely absent. As the patient recovers from the shock, first the tendon- 
reflexes return, and then the skin-reflexes. In those patients who emerge 
from the condition of shock to enter the stage of intracranial pressure. 
the abdominal reflexes will frequently appear depressed on the side opposite 
to the cerebral hemisphere more compressed and the cerebral lesion, and at 
the same time it is usually possible to obtain a definite Chaddock reflex ; 
but the Babinski reflex is absent, and reappears only later, especially if 
the abdominal reflex cannot then be elicited. It mav be that the Chad- 



38 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

dock method of eliciting the dorsal extension of the great toe is possibly 
a more delicate one than the Babinski method, as it is in many patients 
its forerunner. 

These reflexes usually become more and more active, until they are. dis- 
tinctly exaggerated, and if either pyramidal tract is compressed or injured 
intracranially, then the definite signs of such involvement are to be recog- 
nized on the opposite side of the body by the patellar- and ankle-clonus, 
the extensor flexion of the large toe upon plantar stroking (Babinski 's 
sign), and markedly increased tendon-reflexes of the arm and leg, whereas, 
at the same time the abdominal skin-reflexes are usually lessened or even 
abolished. It is, however, rare for these signs to be unilateral alone, unless 
in patients with lesions affecting only one side of the cortex and especially 
in the presence of a large unilateral extradural hemorrhage. In the major- 
ity of cases of brain injuries, both sides of the brain have been so damaged 
and impaired by the general increase of the intracranial pressure by hemor- 
rhage and cerebral edema, that there is a marked exaggeration of the 
reflexes of both sides of the body, and in many patients a bilateral extensor 
reflex of the toes ; this latter sign may last but a few hours in the mild cases, 
showing that no extensive damage has occurred to the pyramidal tracts. 
However, it is a very reliable sign, and its presence is always very signifi- 
cant. In patients where one side of the cortex has been damaged more than 
the other side, the clonus and the Babinski sign will persist on the side of 
the body opposite the more damaged cerebral hemisphere, and gradually fade 
away upon the side of the body opposite the less damaged cerebral cortex. 

Besides the tendon-reflexes in the arms as a means of ascertaining a 
lesion of the pyramidal tract, a sign similar to the Babinski reflex of the 
foot is frequently useful in the hand — the so-called Hoffman sign; by 
pinching sharply the end of the forefinger, the terminal phalanx of the 
thumb flexes briskly if there is a definite lesion of the pyramidal tract of 
the opposite side ; this sign, however, is less frequently elicited than the 
Babinski sign. 

Increased intracranial pressure due to a simple edema alone is sufficient 
to produce these signs of pyramidal tract impairment, and the signs will 
persist as long as the edematous condition remains — in the mild cases for 
several days, and in the more severe cases for two weeks, and even much 
longer. In a number of patients having brain injuries of moderate severity, 
exaggerated reflexes, and even a bilateral Babinski reflex, may often per- 
sist longer than three months after the date of the injury, associated usually 
with a general nervous instability characterized by restlessness, irritability, 
and emotionalism of the extreme type, the patient being much depressed, 
with frequent crying spells, and very easily angered. 

Thus, in patients having high intracranial pressure, careful and most 
thorough neurological examinations are essential in localizing accurately, 
whenever possible, the exact site of the intracranial hemorrhage. Naturally, 
the hemorrhage should be drained, if possbile, but it is rather infrequent 
in these patients that this can be done. It is usually more important in the 
treatment to offset the intracranial pressure of the hemorrhage by a simple 
operative procedure of decompression and drainage in the subtemporal 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 39 

area, rather than to attempt a removal of the hemorrhage itself by the more 
extensive operation of an osteoplastic ' ' flap ' ' over a more highly developed 
area of the cerebral cortex. If the intracranial pressure is high, then 
the underlying cortex may be permanently damaged by its protrusion either 
through the "bone flap" opening or through the common small trephine 
opening — a most dangerous and inadequate procedure. 

12. Pupillary Changes. — Owing to the presence of initial shock of 
varying degree in almost all of these patients having brain injuries, the 
pupils are usually slightly enlarged when associated with a mild condition 
of shock, and widely dilated in the more severe stages of shock ; the reac- 
tion to light is correspondingly sluggish. If the patient is also unconscious, 
then the pupillary dilatation and the sluggish reaction to light are always 
increased. The presence of alcoholism is also a factor in accentuating this 
change. As the patient recovers from the condition of shock, and regains 
consciousness (if that has been prolonged), the pupils usually return to 
normal size and light reaction, and remain so unless there is present a 
definite increase of the intracranial pressure. In this latter condition the 
pupils may remain slightly enlarged, with sluggish reaction to light. 

A marked constriction and "pin-point" pupils result from a cortical 
irritation of a supracortical hemorrhage and mild cortical edema, producing 
the "irritative" stage of pupillary contraction. If this cortical irritant 
of hemorrhage and edema increases until the supracortical and cortical 
pressure becomes high enough to compress the cortical nerve cells, then the 
pupillary narrowing of the "irritative" stage yields to the pupillary 
dilatation of the "paralytic" stage, due to the compression of the cerebral 
cortex, and thus dilated pupils with sluggish light reaction appear. This 
pupillary phenomenon can be frequently observed in patients having 
brain injuries in the progress of a supracortical hemorrhage and cerebral 
edema. If morphia has been administered to control the patient, or if the 
patient is an addict, then careful and accurate ophthalmoscopic examina- 
tions can still be made, while the accuracy of the spinal mercurial manometer 
in registering the pressure of the cerebrospinal fluid is in no way impaired. 

Inequality of the pupils persisting after the initial stage of shock may 
be due to a direct impairment of the third cranial nerve (oculi motorius), 
the cervical sympathetic branches, or, and most frequently in these traumatic 
patients, to the influence of the presence of hemorrhage and edema upon 
the cerebral cortex of either hemisphere. The third cranial nerve is less 
easily impaired than the sixth (abducens), but it may be temporarily 
compressed or even severed in rare cases, producing an enlargement of the 
pupil (owing to the unopposed action of pupillary dilatation of the cervical 
sympathetic) and a weakness particularly of the internal rectus muscle o( 
the eye, and thus an outward rotation of the eyeball (unilateral divergent 
strabismus), owing to the unopposed action of the external rectus muscle 
(supplied by the sixth nerve). Unilateral constriction of the pupil may be 
due to an impairment of the homolateral cervical sympathetic system ami 
its connecting spinal brandies in the lower cervical and upper dorsal nerve 
roots, thus permitting the unopposed constricting action o\' the third nerve. 
It must be remembered that, in the irritative lesions oi' the third nerve and 



4 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the cervical sympathetic, their normal action is usually increased, so that 
an irritative lesion of the third nerve produces a pupillary constriction, 
whereas a similar lesion of the cervical sympathetic causes a dilatation 
of the homolateral pupil. (This latter pupillary phenomenon can be strik- 
ingly demonstrated by pinching the skin at the base of the neck over the 
outer third of the clavicle, when an immediate enlargement of the homo- 
lateral pupil will be easily observed.) 

The usual cause of pupillary inequality in these patients having brain 
injuries after the acute stage of shock has been passed is the pupillary 
constriction of an "irritative" lesion of the cerebral cortex of the homo- 
lateral hemisphere — that is, if the supracortical hemorrhage or cerebral 
edema is of mild degree, and only sufficient to be an irritant of the cerebral 
cortex, then the homolateral pupil is narrowed; whereas, if the pressure 
of the supracortical hemorrhage and edema increases until it compresses 
the underlying cerebral cortex, then the homolateral pupil becomes enlarged, 
and in the severe cases of cerebral compression the pupillary dilatation 
may be the maximum possible. 

These pupillary changes, however, -are of the greatest significance only 
when the entire clinical picture is considered. In the absence of the 
more accurate signs of increased intracranial pressure, as elicited by the 
ophthalmoscope and the spinal mercurial manometer, then a pupillary 
"paralytic" dilatation is of interest, but of little importance in the treat- 
ment of the patient ; and, conversely, a pupillary * ' irritative ' ' constriction, 
in the absence of other signs of cortical irritation, such as extreme restless- 
ness and even localized convulsive seizures, is an interesting observation, 
but not in itself of sufficient importance to warrant a marked change in the 
treatment of the patient. The expectant palliative treatment of such a 
patient could never be abandoned for the operative treatment merely on 
account of these pupillary changes alone. They should always be noted, 
however, in order to complete the clinical picture, and thus to aid in the 
diagnosis of the actual intracranial condition as accurately as possible. 

13. Urinary Findings. — It is very important that a routine examination 
of the urine should be made as early as possible in each patient having a 
brain injury. The associated unconsciousness may be due primarily to a 
cardio-renal disease, which must be eliminated as a possibility. So common 
are the complications of cardio-renal and arteriosclerotic diseases in these 
adult patients of middle age and older, that it is essential to ascertain their 
presence or absence in order to vary the treatment accordingly, and also to 
insure the probable prognosis — always a most difficult task, and one which 
must be most guarded. The effect of chronic alcoholism can also be esti- 
mated. The great danger in these patients having nephritic complications 
is the acute onset of cerebral edema — a "wet," edematous brain to which 
they are all especially liable, even if the cranial injury is apparently a trivial 
one. In some of these patients it would seem that mere confinement in bed 
for 24 hours increased their susceptibility to an acute cerebral edema, being 
particularly so in the development of delirium tremens in chronic alcoholics. 

Brain injuries affecting the pituitary body, and especially basal frac- 
tures extending into the middle fossa and across the sella turcica, will fre- 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 4 r 

quently cause sugar to be temporarily excreted in the urine, as disclosed 
by the Fehling reaction and the other routine tests. This appearance of 
sugar rarely occurs before six hours after the cranial injury, and, in this- 
series of patients, it has never been demonstrated to persist longer than 
36 hours — that is, the pituitary lesion is thus merely an irritative one affect- 
ing the anterior lobe, rather than a definite lesion or destruction of its. 
cells themselves. 

14. Ophthalmoscopic Findings. — The presence or not of "choked disks " 
as the sign of an increased intracranial pressure has possibly retarded the 
recognition of the earlier signs of an increased intracranial pressure more 
than any other factor. It is still commonly believed that unless a ' ' choked 
disk" — a papilledema — of 2 diopters or more, is present, then there is no 
increase of the intracranial pressure, and thus overlooking the earlier de- 
grees of intracranial pressure such as a dilatation of the retinal veins r 
an edematous blurring of the margins and an edema of the halves of the 
optic disks themselves, but not of a measurable swelling, or, if so, then merely 
a papilledema of one or two diopters, these being the preliminary stages 
of the condition of " choked disks, ' ' which is the advanced result of very high 
intracranial pressure. Merely because this extreme condition of "choked 
disks" is not present does not mean that there is not a definite increase of 
the intracranial pressure, and of sufficient degree to produce the dangerous 
complication of medullary compression, and even edema itself. It is these 
early stages of the fundal signs of an increased intracranial pressure which 
have been overlooked in the past, but which can now be demonstrated 
and also confirmed by means of the spinal mercurial manometer at lum- 
bar puncture. 

Besides the lowered pulse- and respiration-rates, which are compara- 
tively crude signs of intracranial pressure, and if of the irregular Cheyne- 
Stokes type, then most late signs of extreme intracranial pressure with its 
resulting medullary compression, the two most valuable procedures for 
determining a definite increase of the intracranial pressure are the exam- 
inations of the fundi of the eyes with the ophthalmoscope, and the measure- 
ment of the pressure of the cerebrospinal fluid at lumbar puncture by 
means of the spinal mercurial manometer. 

Although it is rare for a measurable papilledema and "choked disks" 
to occur in these patients having traumatic intracranial lesions, with and 
without a fracture of the skull, yet the earlier, and, therefore, milder 
degrees of an edema of the optic disks should be most carefully "watched 
for" with the ophthalmoscope, as being one of the accurate signs of the 
presence or not of a definite increase of the intracranial pressure. The 
ophthalmoscope (Fig. 13), and especially the "direct" method, using an 
electric light, is a most valuable aid in the diagnosis of intracranial lesions. 
Proficiency in the use of this instrument is essential to accurate diagnosis; 
one should practice first with normal eyes, so that any abnormal dilatation 
of the retinal veins and edematous changes of the optic disks may quickly be 
noted. The proficient use of this "direct" method in the examination of 
the fundus is not only simpler and easier to acquire than the old "indirect" 
method of reflected light and an interposed lens, but it is much more 



42 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

accurate in revealing the minute details and changes in the 
fundus of the eye. With the "indirect" method, it is some- 
times difficult to distinguish slight pathological changes oc- 
curring in the fundus. 

In occasional cases of severe concussion, with and without 
a fracture of the skull, it is possible for the opthalmoscope to 
reveal a slight dilatation of the retinal veins, that is, a mod- 
erate degree of increased intracranial pressure. In mild 
cases, the intracranial pressure does not advance beyond this 
height, which produces merely a dilatation of the retinal ves- 
sels, and in many of the cases of simple concussion not even a 
dilatation of the retinal veins results. 

It is in those patients, however, having not only a dilata- 
tion of the retinal veins, but the added blurring and haziness 
of edematous optic disks, that we should be careful to make 
repeated ophthalmoscopic examinations of the fundi in order 
to ascertain the earliest signs of a still increasing intracranial 
pressure — whether it is due to a simple edema of a "swollen" 
brain or to a hemorrhage. The signs of a still increasing 
intracranial pressure beyond a dilatation of the retinal veins 
are, first, an edematous blurring and obscuration of the nasal 
pie electric oph- margin of the optic disk (Fig. 14), then a similar haziness 
haif™h e S a?tuais°i?e) of its temporal margin, then the nasal half is obscured, and, 

for the determina- 
tion of the presence 
or not of an in- 
creased intracra- 
nial pressure, and condition of papilledema; if a measurable swelling of 2 

its degree, bv the ax? o 

direct method, diopters plus, then the condition of "choked disk." 

Two small electric /. ......... . - . , 

batteries are en- Those patients having brain injuries with an increased 
intracranial pressure sufficient to produce a dilatation of the 
retinal veins and a blurring and haziness of the nasal margins 



finally, the blurring of the temporal half, resulting in the 
severe cases in the total obscuration of the optic disk — the 



closed in the cylin 
drical metallic han- 
dle so that this use- 
ful instrument may 
be easily carried in 
a coat pocket — it 



of the optic disks, can still be treated successfully by the 
?? o n e e n - g h I e ff expectant palliative treatment ; but if the ophthalmoscope re- 
pound, itssim- veals a still greater pressure, sufficient to cause an obscura- 

phcity and dura- . « -, -1 n -1 -i-it c n 

biiity minimize the tioii oi the nasal and even the temporal halves 01 the optic 

frTm 1 ca/eYess disks — that is a beginning papilledema — then it is always ad- 

v«y early ftagesof visable and safer to relieve the increased intracranial pressure 

wen ll as 3d t£ a 'ad- as early as possible; whether it is due to cerebral edema or to 

"chSkedd e i£?' S ca°n hemorrhage, the principle remains the same. In these latter 

be accurately pa tients a decompression and drainage is advisable, not only 

measured without ^ j. _ ^ 

the necessity of to save the life of the patient by avoiding a medullary edema, 
the 1 interposition but to lessen the severity and number of the post-traumatic 
?uir n e S d S, by S th^ conditions so frequently following a prolonged increase of the 
m^t^dof ^phtSS- intracranial pressure. 

moscopic examina- Unless the intracranial pressure is very high, resulting 
from a large, rapid hemorrhage, it is very unusual for 
the ophthalmoscope to reveal marked changes in the fundus within three 
hours after the injury. The veins may become full and dilated, but it 
is rare for an obscuration of the details of the optic disks to occur within 
this period; if it does, then an immediate decompression and drainage is 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 43 

most advisable. In this series of 487 patients, it was observed that frac- 
tures of the occipital bone beneath the tentorium and around the foramen 
magnum were usually responsible for this rapid and high increase of the 
intracranial pressure, due possibly to a blockage of the aqueduct of Sylvius, 
and consequently the ventricle, by either a subtentorial hemorrhage or a 
cerebellar edema — that is, similar to the signs of pressure resulting from 
subtentorial lesions blocking the ventricles, whether a tumor, an abscess or a 
cyst. Frequently the intracranial pressure may become so high that the 
extracranial vessels in the scalp, and especially of the upper eyelids, become 
filled and dilated, due to the blockage of the venous circulation intracranially. 
The prognosis is very poor in these patients, operation or no operation ; an 
early medullary edema is the usual outcome, these patients dying within 
six to ten hours after the cranial injury. 




Fig. 14. — A schematic representation of the ophthalmoscopic picture of the fundus of the right eye. 

A. Normal fundus — details of optic disk clear, retinal arteries and veins of normal size. 

B. Marked increase of the intracranial pressure — nasal half of optic disk obscured by edema, retinal 
arteries small and retinal veins enlarged. 

C. High increase of the intracranial pressure— a papilledema — all the details of the optic disk obscured 
by edema, and if a measurable swelling above two diopters, then the condition is called "choked disks"; 
the retinal arteries are small, while the retinal veins are dilated, tortuous and in places buried in edematous 
tissue. A secondary optic atrophy from new tissue formation results, in varying degree, if this latter con- 
dition is permitted to persist for a period of weeks, and surely of months. 

It is, however, in those patients who do not show marked signs of high 
intracranial pressure until three hours or more following the injury that 
a better prognosis can be given. Repeated ophthalmoscopic examinations 
are essential — at least once every hour — and if the changes in the fundi 
advance beyond a fulness of the retinal veins and an edematous blurr- 
ing of the nasal halves of the optic disks, then an immediate decom- 
pression and drainage is advisable. Fortunately, however, with the aid of 
the expectant palliative treatment the intracranial pressure does not in- 
crease beyond this degree in almost 70 per cent, of the patients having 
brain injuries, with and without a fracture of the skull, so that no operation 
is necessary in seven out of ten patients, and the recovery will be uneventful 
with medical treatment alone. It may require four to six days, and even 
longer, for these signs of a moderate increase of the intracranial pressure 
to subside, but apparently this duration of moderate pressure does not 
produce any harmful effects. 

Rarely do these fundal examinations reveal a marked increase o( the 
intracranial pressure within six hours after the cranial injury; this is 
due to the presence of shock in these patients, who later exhibit the marked 
signs of intracranial pressure. As cranial injuries are usually accompanied 



44 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

by shock of varying: degrees, it follows that in these patients the blood- 
pressure is low, so that even if a large intracranial vessel was torn, yet there 
could be only a comparatively small amount of hemorrhage, because the 
resulting increased intracranial pressure would soon be greater than this 
lowered blood-pressure of shock, and therefore the bleeding would cease. 
However, as the patient recovers from the condition of extreme shock, then 
the blood-pressure would rise, and now more bleeding could occur intra- 
cranially until the intracranial pressure would again equal the lowered 
blood-pressure. Finally, if the patient survived this condition of shock, 
then the blood-pressure would be continuously greater than the intracranial 
pressure, so that this resulting increased intracranial pressure would produce 
its characteristic signs in the fundus of the eye — a dilatation of the retinal 
veins and an edematous blurring of the nasal and temporal margins, then 
the nasal halves, and, if still higher, then an edematous obscuration of 
the temporal halves of the optic disks. A measurable papilledema and 
' ' choked disks ' ' occur in these patients only when the intracranial pressure 
is extreme, due to a large intracranial hemorrhage of slow formation, such 
as the extradural middle meningeal type — just as in brain tumors, or when 
the ventricles are blocked, producing an internal hydrocephalus. Hence, 
if the intracranial hemorrhage forms very rapidly and of large amount, 
the patient usually dies within two or three hours, so that "choked disks " 
have very little time to be produced. Again, the shock following head 
injuries usually lasts for about six hours in the patients who survive, and 
therefore it is rare within these first six hours for the ophthalmoscope to 
reveal definite signs of an increased intracranial pressure. It may be also 
noted that the patients who do not survive the condition of shock usually 
die within the first six hours. It is, therefore, of the greatest importance 
to recognize these early signs of increased intracranial pressure by repeated 
ophthalmoscopic examinations, and to realize that these edematous blur- 
rings of the optic disks are more than being merely within physiological 
limits. It is true that in cases of myopia there is normally an obscuration of 
the disk outlines, but these patients can be excluded by the measurement 
of the cerebrospinal fluid by means of the spinal mercurial manometer, 
which should always be used in these patients. 

15. Lumbar Puncture Findings. — The normal pressure of the cerebro- 
spinal fluid is 5-9 mm. as registered by the spinal mercurial manometer at 
lumbar puncture. Any increase over 12 mm. may be considered as being 
above physiological limits, and therefore indicating a pathological con- 
dition within the cerebrospinal canal. The use of the ophthalmoscope is 
important in these patients in corroborating the lumbar puncture findings, 
but negative fundi do not exclude the presence of an increased intracranial 
pressure of mild degree, the ophthalmoscope being a more crude and less 
accurate means of determining the milder increases of intracranial pressure 
than the spinal mercurial manometer. It is this estimation of the intra- 
cranial pressure which is of importance in the treatment of patients having 
brain injuries — whether the expectant palliative treatment to facilitate the 
absorption of mild increases of intracranial pressure by natural means will 
suffice (and it does in almost 70 per cent, of the patients having brain 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 45 

injuries), or the necessity for an early mechanical lowering of the high 
intracranial pressure by means of the cranial operation of subtemporal 
decompression and drainage (indicated in only about one-third of the 
patients) in order not only to obtain a larger percentage of recovery of life, 
but also to secure as normal an individual as before the injury. 

The presence of free blood in the cerebrospinal fluid at lumbar puncture 
in these patients is only of importance as an added sign of the intracranial 
injury, and merely denotes bleeding from an intradural vessel, with and 
without a fracture of the skull. The absence, however, of free blood in 
the cerebrospinal fluid does not exclude an intracranial hemorrhage, and 
even a subdural and subarachnoid hemorrhage. This observation has been 
repeatedly made, both at lumbar puncture and then at the later cranial 
operation. It would seem that in some of these patients there was a blockage 
of the normal descent of the cerebrospinal fluid into the spinal canal, and 
thus the intracranial hemorrhage was not demonstrated at lumbar puncture ; 
naturally an extradural hemorrhage of the middle meningeal type does not 
in itself cause free blood to be revealed in the cerebrospinal fluid. The 
presence of blood in the cerebrospinal fluid, therefore, is of no importance 
in the treatment of the patient regarding the advisability or not of a cranial 
operation, which procedure depends entirely upon the presence of a high 
intracranial pressure which is not considered absorbable by natural means 
under the expectant palliative treatment, and the presence or not of blood in 
the cerebrospinal fluid or of a fracture of the skull (unless it is a depressed 
fracture of the vault) is of little or no importance in the treatment of 
these patients. This attitude toward the treatment of brain injuries 
cannot be too strongly emphasized, for the opinion has become firmly 
rooted in the medical profession that in the presence of blood in the cerebro- 
spinal fluid, and the definite signs of a fracture of the skull, then the treat- 
ment by one extreme group is the expectant palliative one — no cranial opera- 
tion under any circumstances, even when associated with a high intracranial 
pressure; whereas the other extreme group would advocate a cranial opera- 
tion merely because a fracture of the skull and the presence of blood in the 
cerebrospinal fluid indicated a serious intracranial condition, whether there 
was an increased pressure or not. These two extreme views should be 
modified until it is definitely recognized that the degree of intracranial 
pressure, as ascertained by the ophthalmoscopic and spinal manometric 
examinations, together with the general condition of the patient, is the chief 
and deciding factor in the method of treatment of these patients. 

The measurement of the pressure at lumbar puncture, therefore, is of 
the greatest importance, and it should be performed in each patient as early 
as possible after the signs of initial shock have disappeared. If a lumbar 
puncture is performed during the stage of initial shock, then the procedure 
is merely an added shock to the patient, while the pressure of the cerebro- 
spinal fluid in the severe degrees of shock is always normal and even sub- 
normal — as low as 3-5 mm. ; the blood-pressure being subnormal from the 
shock, then the intracranial pressure is also low from the same cause, and 
no extensive intracranial hemorrhage or cerebral edema can occur until the 
period of shock has been survived. 



46 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

The condition of initial shock having disappeared, as indicated by the 
temperature and blood-pressnre ascending to normal and above, and the 
pnlse- and respiration-rates descending to and below 100 and 26 respec- 
tively, then it is advisable in these patients to examine repeatedly the fundi 
ophthalmoscopically, and to measure the pressure of the cerebrospinal fluid 
at lumbar puncture by means of the spinal mercurial manometer. A mild 
increase of the intracranial pressure is usually present, but in only about 
one-third of the patients will the ophthalmoscope disclose an edematous 
blurring of the nasal halves of the optic disks, and the spinal manometer 
register a pressure over 16 mm. — that is, it is only in these 30 per cent, of 
the patients having brain injuries that the operation of cranial decompres- 
sion and drainage is advisable, in order to obtain a larger percentage both of 
recovery of life and of the former good health and normality; whereas the 
larger number of the patients — about two-thirds of them — do not reveal an 
increased intracranial pressure or a higher pressure than is disclosed by 
the ophthalmoscope in the enlargement of the retinal veins and the obscura- 
tion of the nasal margins of the optic disks, while the spinal manometer 
usually registers a pressure approximating the normal, and within physio- 
logical limits (10 mm. in adults), or not higher than 12 mm. It is in these 
latter patients, in whom the pressure does not exceed 16 mm., that the 
expectant palliative method of treatment is sufficient for an excellent 
recovery of life and former mentality to be obtained, and it is only in about 
30 per cent, of the patients that the intracranial pressure exceeds 16 mm., 
and these are the ones to whom the operation of subtemporal decompression 
and drainage offers the highest percentage of recovery of life and the best 
chance of ultimate normality. In the absence of a marked increase of the 
intracranial pressure, it is only in those patients having the symptoms and 
signs of localized cortical irritation, due to a small circumscribed supra- 
cortical or cortical hemorrhage and cortical edema sufficient to cause a 
definite cortical impairment, such as paralysis or convulsive seizures, that 
the operation of cranial exploration and drainage is advisable. This opera- 
tive procedure is usually best performed by means of the subtemporal route. 
Depressed fractures of the vault of the skull producing similar cortical 
impairment necessitate the early operative removal of the depressed area of 
bone, and, if associated with a marked increase of the intracranial pressure, 
then a subtemporal decompression and drainage would be indicated first, to 
be followed at the same operation by the removal of the bony depression 
of the vault. It must be remembered that an extensive laceration of the 
cortex can occur with only a mild increase of the intracranial pressure, due 
to a small amount of resulting hemorrhage and edema of the adjacent cortex. 
If the motor area of either cerebral cortex is thus impaired, and particu- 
larly the cortex of the left hemisphere, which is possibly more highly 
developed in right-handed patients than the right cerebral cortex, then the 
paralysis may be very pronounced, and yet only mild signs of an increased 
intracranial pressure be revealed. As a rule, however, the signs of an 
increased intracranial pressure in these patients are very definite, and 
frequently above 16 mm., owing to the associated free hemorrhage and the 
extensive cerebral edema of the contiguous cortex and subcortical nerve 



THE SYMPTOMS AND SIGNS OF ACUTE BRAIN INJURIES 47 

tissues, and therefore the operation of decompression and drainage is 
advisable to lower the pressure and thereby obtain the greatest return of 
cerebral function of the cortical cells, which have not been destroyed but 
merely compressed by the local hemorrhage and edema — that is, only 
functionally impaired. 

The highest pressure registered by the spinal mercurial manometer in 
this series of patients having brain injuries was 44 mm. The patient was 
an unusually able-bodied Italian laborer, of 36 years of age, and only semi- 
conscious. The ophthalmoscope disclosed the condition of choked disks of 
3 diopters. At the operation of subtemporal decompression and drainage 
upon the seventh day after the injury, a profuse subdural hemorrhage was 
evacuated, while the cerebral edema was extreme. Fortunately, the patient 
made an excellent recovery. (Vide Case 46, page 256.) 

The lumbar puncture when used therapeutically to remove the excess 
cerebrospinal fluid and free blood in the mild cases of increased intracranial 
pressure, and thereby improve the general condition of the patient by 
lessening the severe headache, restlessness, etc., frequently revealed the pres- 
sure of the cerebrospinal fluid as being 14 to 16 mm. at the beginning- 
of the puncture drainage ; and after 15 to 20 c.c. were removed, then the 
pressure would be only 10 to 12 mm. This temporary improvement would 
last, as a rule, only about 12 hours after the first three or four punctures ; 
and then if this means of lessening the pressure, together with the expectant 
palliative treatment, was sufficient, the registration of the spinal manometer 
would become lower and lower, until it was no longer necessary to continue 
the drainage by lumbar puncture. The patients who can be satisfactorily 
treated by this method are comparatively few, and yet it is a drainage 
procedure frequently applicable in new-born babies and children, and in 
the milder conditions of increased intracranial pressure in adults, produc- 
ing the symptoms and signs of severe headache, extreme restlessness, ver- 
tigo, nausea, vomiting, etc. This method should never be substituted, 
however, for the cranial operation of decompression and drainage in the 
patients having a high intracranial pressure (over 16 mm.) — the risk of a 
direct medullary compression in the foramen magnum would be too great. 

16. Traumatic Cerebral Edema. — The pathology of traumatic cerebral 
edema is both obscure and puzzling. It may be similar to a localized 
traumatic edema as occurs elsewhere in the body : a blow upon the arm 
causes that part of the arm to swell, so that a "bump" is present: this 
swelling is due to congestion of the neighboring blood-vessels, an outpouring* 
of blood serum from the small capillaries, and is also caused by an increase 
of the lymph, due possibly to a retarded lymph-flow. In cranial injuries, how- 
ever, and well illustrated in the more severe forms of so-called k ' concussion. ' * 
there occurs frequently a mild edema of the brain — that is, there is a slight 
increase of the intracranial pressure, as ascertained both by the ophthalmo- 
scopic examinations of the fundi of the eyes, revealing an edematous blurring 
of the optic disks of varying degree, and by the measurement of the pressure 
of the cerebrospinal fluid at lumbar puncture by means of the spinal mer- 
curial manometer. The latter test reveals in these patients a definite increase 
in the amount of fluid, bathing, and buoying the central nervous system. 



48 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Is this increase of subarachnoid fluid following head injuries merely 
an increase in the amount of cerebrospinal fluid secreted, or is it a tem- 
porary retardation of the excretion of the cerebrospinal fluid through its 
normal channels — the cortical veins chiefly, the sinuses, Pacchionian bodies, 
and possibly the lymphatics — just as in the more permanent blockage of 
cerebrospinal fluid that occurs in the external type of hydrocephalus? Or 
is this "wet" serous condition of the brain following trauma merely an 
outpouring of blood serum from the congested and dilated blood-vessels? 
Or could it possibly be influenced by the presence of a retarded flow of 
lymph in the brain, or an increase in the amount of lymph itself ? 

As neither lymph nor lymph-channels within the cerebrospinal nervous 
system have ever been demonstrated, the possibility of this last factor 
must necessarily be, at least for the present, of theoretical interest only. An 
outpouring of blood serum from the dilated intracranial blood-vessels is 
a possible factor to some extent. My own impression, however, is that 
cerebral edema frequently results from an increase in the amount of cerebro- 
spinal fluid secreted by the choroid plexus chiefly, and also, — and I believe 
this is the main cause of traumatic cerebral edema, — from the partial 
blockage of the excretion of cerebrospinal fluid, due to congestion and a 
temporary retardation of the flow of intracranial blood in the cortical 
veins and sinuses. The latter cause in itself is sufficient to produce the con- 
dition of a " wet, ' ' edematous, water-logged brain of varying degree, and of 
such frequent occurrence in cranial injuries — that is, traumatic cerebral 
edema is really an increase in the amount of cerebrospinal fluid both in and 
around the cerebral tissues. 

The presence of an increase in the number of cells in the cerebrospinal 
fluid in these conditions would merely indicate a certain degree of meningeal 
irritation, due both to the trauma and to the vascular congestion. At times, 
a meningismus producing a stiffened neck and even Kernig 's sign may 
~be elicited in the more severe conditions of so-called "concussion." It is 
in these patients with a moderate increase of the pressure of the cerebrospinal 
Huid that merely a lumbar puncture, and frequently repeated lumbar punc- 
tures, suffice to decrease the amount of cerebral edema, so that its symptoms 
and signs disappear within several days. The question of cerebral edema, 
however, is not at all settled, and it offers a large field for experimental work. 

The condition of chronic cerebral edema persisting for months and even 
years after the cranial injury is due, I believe, to a partial blockage of the 
excretion of the normal amount of cerebrospinal fluid into the cortical 
veins and sinuses, resulting from the organization of subdural and sub- 
arachnoid hemorrhage occurring at the time of the cranial injury. In the 
patients in whom the blockage is sufficient to produce the condition of mild 
external hydrocephalus, and thus a resulting increase of the intracranial 
pressure, the pathology as disclosed at operation to lower this pressure is 
a connective tissue thickening and cloudy induration about the vessel walls 
— the supracortical veins and sinuses — and especially in the sulci, so that 
the stomata of exit of the cerebrospinal fluid in their walls are partially 
blocked and thus the condition of a mild external hydrocephalus develops 
similar to that type of external hydrocephalus following a mild menin- 
gitis when the ventricles are not blocked. 



CHAPTER IV 

The Significance" of Intracranial Pressure 

Under normal conditions, the height of intracranial pressure depends 
upon the general arterial blood-pressnre in a direct ratio — the higher the 
blood-pressure the higher the intracranial pressure, and the lower the blood- 
pressure the lower the intracranial pressure. This ratio remains constant 
unless marked pathological lesions occur intracranially, such as a large 
hemorrhage or the terminal stages of a large tumor formation ; then the 
increased intracranial pressure may exceed the general arterial blood- 
pressure, temporarily and periodically at first, but if not relieved, then 
permanently, resulting eventually in the death of the patient. Naturally, 
the intracranial pressure is highest in the arteries, and then in the capil- 
laries, and lowest in the cortical veins and the large venous sinuses. Other 
conditions remaining the same, any increase in the amount of inflow of 
blood, or any blockage of its outflow, produces a rise of intracranial pressure. 

Another factor, however, in intracranial pressure is the cerebrospinal 
fluid. Secreted by the choroid plexus of veins in the third ventricle, it passes 
into the lateral ventricles and also backward through the aqueduct of 
Sylvius into the fourth ventricle, where it escapes through the foramina of 
Majendie and Luschka into the subarachnoid spaces to bathe, as it were, 
the cortex of the brain and the surfaces of the spinal cord — floating them 
to a certain extent. It is now believed that the cerebrospinal fluid re-enters 
the circulation chiefly by means of the cortical veins and also through the 
Pacchionian bodies situated along the longitudinal sinus. Whether this 
fluid brings nourishment to the nerve cells or carries away waste products 
is unknown. The amount of cerebrospinal fluid depends upon many fac- 
tors, especially the rate of its secretion and the rate of its excretion. In 
the most common types of external hydrocephalus, the increased amount of 
cerebrospinal fluid is due to a lessened excretion by blockage of its stomata 
of exit in the cortical veins and sinuses. Temporarily, at least, the amount 
of cerebrospinal fluid tends to be increased by a rise in the blood-pressure : 
especially is this so in traumatic conditions of the skull and particularly 
in brain injuries with and without a fracture of the skull. 

One effect of a prolonged increase of the intracranial pressure is the 
resulting partial anemia of the cortex; the amount of blood reaching the 
cortex is thus lessened, so that the delicate cortical nerve cells do not receive 
their normal blood supply; a partial "starvation" of them results, so that 
the cortex becomes pale, and if this condition persists for any length of 
time, then an increase of neuroglia cells occurs in it. This increase of 
neural connective tissue tends to prevent the normal functioning of the 
cortical nerve cells, and is, in my opinion, the cause of many of the so-called 
" post-traumatic neuroses ' ' following brain injuries, such as persistent head- 
aches, dizzy spells, indefinite pains in the head, changed personality to one 
of emotional excitement and irritability or to one of depression, general 
4 49 



5 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

nervous instability, fainting spells and even epilepsy itself. A high intra- 
cranial pressure persisting ten days or more is apparently sufficient to 
produce these conditions. One case at autopsy, following a brain injury 
with fracture of the skull 8 years previously, showed a marked increase 
of the neuroglial tissue cells in the cortex; since the cranial injury, beside 
the definite signs of an increased intracranial pressure, the patient had 
suffered from intense headache and at times even epileptiform attacks. 
There may have been in this patient subpial punctate hemorrhages causing 
an unusual amount of connective-tissue formation in the cortex. 

A number of years ago, Kocher, by careful observations, recognized the 
symptoms and signs of increased intracranial pressure and divided clinically 
the resulting intracranial compression into four main stages. These are : 

The First Stage of Compression, Being the Medical Stage of Compen- 
sation. — The effects of increased intracranial pressure vary according to 
whether the compression is sudden and acute, or gradual and chronic ; if 
the latter, then a certain amount of adaptation of the brain occurs, so that a 
much higher pressure may be endured without producing the marked signs 
of its presence ; this occurs very frequently in slowly growing tumor forma- 
tions of the brain. In either case, whether acute or chronic, the increased 
intracranial pressure first expels the excess cerebrospinal fluid and, as brain 
tissue itself is non-compressible, it then compresses the local blood-vessels, 
so that the amount of intracranial blood is slightly lessened. As the blood 
in the cerebral veins is under a very low pressure, these veins become filled 
with blood and dilated, so that the next sign is a venous stasis — its symp- 
toms being headache, drowsiness, and possibly stupor ; the pulse, respiration 
and blood-pressure are not affected ; the retinal veins become dilated. (Even 
in this first stage, a slight haziness and edematous blurring of the nasal 
margins of the optic disks may be observed. The pressure of the cerebro- 
spinal fluid by the spinal mercurial manometer may register 12-14 mm. of 
mercury. Naturally, the expectant palliative treatment is indicated, and in 
over two-thirds of the patients this treatment alone suffices to insure an 
excellent recovery in this medical stage of increased intracranial pressure.) 

The Second Stage of Compression, Being the Ideal Operative Stage. — 
If, however, the intracranial pressure still rises, it tends to approximate the 
pressure in the capillaries, and so a partial anemia results. If the pressure 
is a local one, such as that due to a middle meningeal hemorrhage or a 
depressed fracture of the vault, then a local anemia of the underlying cortex 
results with impairment of function of that cerebral area. Naturally, the 
more distant the areas of the brain are from the localized compression the 
less are they affected, and as the falx cerebri and the tentorium form three 
fairly separate compartments of the brain, it is possible for one hemisphere 
to be disabled by an extradural hemorrhage, and yet the opposite hemisphere 
and especially the cerebellum and medulla situated beneath the tentorium 
to be only slightly affected ; the tentorium is of the utmost importance in this 
respect — a protecting barrier for the all-important medulla. If, on the other 
hand, the increased intracranial pressure is of subdural origin, due to a 
subdural hemorrhage or a sudden increase in the amount of cerebrospinal 
fluid following a brain injury with and without a fracture of the skull, then 



THE SIGNIFICANCE OF INTRACRANIAL PRESSURE 51 

the pressure becomes general and all portions of the brain are equally 
affected. In the case of a subdural clot, naturally the underlying cortex is 
more compressed than the more distant areas of the brain, although even 
in these cases of general pressure it is the effect upon the medulla that is to 
be feared; subtentorial local pressure of moderate severity produces the 
same medullary impairment as high intracranial and supratentorial 
general pressure. 

The first effect upon the medulla of a continued rise of the intracranial 
pressure is one of slight anemia of the medulla producing a slow pulse 
of 60 or lower due to the stimulation of the vagus nucleus, and a slight 
rise in the general arterial blood-pressure due to the stimulation of the 
vasomotor centre, causing not only a constriction of the peripheral blood- 
vessels themselves, but especially of those vessels of the splanchnic field. 
In addition, the intracranial venous stasis becomes more marked so that the 
headache becomes severe and associated with restlessness and even delirium ; 
a definite cyanosis appears; an ophthalmoscopic examination reveals large 
dilated retinal veins with or without edema of the optic disks. These 
definite, though moderate, signs of high intracranial pressure form the 
second stage of compression clinically, which is undoubtedly the best time 
to operate to relieve the intracranial pressure — before the extreme signs of 
medullary compression have occurred. (In this operative stage of intra- 
cranial pressure, the more modern methods of examining the fundus of the 
eye with the electrical ophthalmoscope (the direct method) rarely fails 
to disclose a definite edematous obscuration of the optic disk outlines — a 
mild papilledema; the spinal mercurial manometer usually registers an 
increased intracranial pressure above 15 mm. of mercury up to 22 mm., 
and at times even higher. Marked stupor usually appears ; unconsciousness 
may or may not be present; if it is present, then it is rarely continuous, 
but is more frequently of the periodic type — an extreme stupor from which 
the patient can be roused and then again cannot be roused by the usual 
methods of supraorbital pressure, inhalation of ammonia, etc. This second 
stage of compression is the ideal operative period both as to immediate 
recovery of life and the permanent recovery of unimpaired function ; it 
anticipates the dangerous stages of extreme medullary compression and 
of medullary edema and collapse.) 

The Third Stage of Compression, Being the Imperative Operative Stage 
of Medullary Compression. — The third stage of compression clinically con- 
sists of the major or bulbar (medullary) signs of compression. As the 
intracranial pressure continues to rise, it produces a greater anemia of the 
medulla so that the intracranial pressure at times may equal the capillary 
pressure of the medulla; if it were not for the regulatory mechanism of the 
circulation in the medulla, such an occurrence would result in the imme- 
diate and permanent cessation of the cardiac and pulmonary activity, ami. 
therefore, the death of a patient. Fortunately, however, as the anemia 
of the medulla becomes greater, this very absence of blood so stimulates 
its vasomotor centre that the general arterial blood-pressure is raised, 
more blood is forced into the medulla, and in this manner the partial 
anemia is overcome, at least temporarily. Clinically, the picture is most 



52 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

striking ; as the intracranial pressure increases nntil it tends to prevent the 
normal flow of blood into the medulla, the resulting partial anemia so stimu- 
lates the vagus centre that the pulse-rate gradually becomes lowered to 
50 and below and of a full bounding character ; the respiration becomes less 
and less frequent until a period of temporary apnea or non-breathing 
results from the anemia of the respiratory centre in the medulla : the patient 
may not breathe for 40 seconds and even longer. During the earlier part 
of this period of "down- wave" of the pulse- and respiration-rates, the 
blood-pressure falls slightly, the patient gradually becoming more and more 
stuporous, the pupils slowly dilating, and the reflexes being abolished — 
the results of a definite anemia of the medulla. Then, as this prolongation 
of the medullary anemia stimulates its vasomotor centre to renewed activity, 
the general blood-pressure is gradually raised to overcome the intracranial 
pressure until blood is forced into the medulla, the heart-rate increases, and 
then the patient begins to breathe again as a result of the respiratory centre 
being resupplied with blood. During this period of ' ' up-wave, ' ' the cyanosis 
is extreme, the pupils contract, and the patient may groan, become restless 
and even regain consciousness ; the reflexes return and the ophthalmoscopic 
examination reveals a double papilledema or "choked disks"; that is, the 
intracranial pressure becomes so high that the resulting venous stasis pro- 
duces an edema of the optic disks so that their margins and the entire disks 
themselves are obscured and the retinal veins are dilated and at times buried 
in the edematous retina; even the other extracranial veins of the scalp, 
and particularly of the upper eyelids, are dilated. As the medulla becomes 
supplied with blood again following this period of "up-wave" of the pulse-, 
respiration- and blood-pressure-rates, the stimulation of its vasomotor centre 
is lessened so that gradually the general arterial blood-pressure diminishes 
until the symptoms and signs of the "down-wave" become more and more 
marked; then the "up-wave" begins again, as outlined above, and this 
periodicity of symptoms and signs depending upon the rise and fall of the 
general blood-pressure causing the Cheyne-Stokes type of pulse and respira- 
tion (Traube-Herring waves) occurs again and again. This condition may 
continue for hours. (This third stage of intracranial compression may be 
known as the period of imperative operation ; unless an immediate decom- 
pression and drainage is performed, it is most rare for these patients to 
survive ; even with operation, the chances for recovery are doubtful. The 
ophthalmoscope reveals a measurable papilledema — even above 2 diopters 
frequently — that is, to a degree of "choked disks." The spinal mercurial 
manometer registers a pressure above 20 mm. of mercury and frequently 
even 30 mm. Unconsciousness is almost always present, either periodic 
or continuous, especially during the period of "down-wave," and always 
during the later and advanced period of this stage. This stage of extreme 
intracranial pressure should be anticipated if possible and it usually can 
be, by the more modern methods of examination and estimation of the 
intracranial pressure as outlined above; no patient should be permitted 
to enter this stage of compression if it can be possibly avoided — the mortality 
being very high.) 

Fourth Stage of Compression, Being the Non-Operative Stage of Medul- 



THE SIGNIFICANCE OF INTRACRANIAL PRESSURE 53 

Jary Edema. — Unless this high intracranial pressure is quickly relieved by 
an operation (and even with an operation the chances for recovery at this 
stage of compression are slight), this regulatory mechanism of the medulla 
will finally become fatigued, so that the vasomotor stimulation will no 
longer be able to raise the general arterial blood-pressure above the intra- 
cranial pressure, and thus during one of the "down-waves," a permanent 
fall of blood-pressure will occur ; respiration will no longer begin again, 
and the heart will continue to beat irregularly and rapidly as a separate 
organ until the blood-pressure gradually falls to zero, so that even the 
heart itself will cease beating. This stage of respiratory paralysis, associ- 
ated with rapid and irregular cardiac efforts, dilated pupils, profound 
coma and complete muscular relaxation and a permanent fall of the general 
arterial pressure, forms the fourth stage clinically of a permanent anemia 
of the medulla — the stage of loss of compensation or the terminal stage, 
always resulting in the death of the patient. (This fourth and last stage 
of intracranial compression might be well known as the non-operative or 
moribund period. Once these patients have entered this stage of medullary 
edema as shown by a rapidly increasing and irregular pulse-rate above 120, 
a low blood-pressure descending to 100 and even lower, and by a rapidly 
increasing, irregular and shallow respiration, then these patients all die — 
operation or no operation; in fact, any operation in this period merely 
hastens the exitus and so tends to discredit cranial surgery. A pulmonary 
edema is usually considered the immediate cause of death, although it is 
really secondary to the medullary edema and collapse. In this series of 
patients having brain injuries with and without a fracture of the skull 
in whom the fourth stage of medullary edema was observed (and these 
patients all died whether they had been operated upon or not), it was 
exceedingly rare for a permanent respiratory paralysis to occur during a 
period of apnea to the extent that death occurred at that time ; the usual 
observation was: a lowered and irregular pulse- and respiration-rate of 
the Cheyne-Stokes type continued until the pulse-rate began to ascend 
rapidly to 120 and above, and at the same time associated with an increas- 
ing respiration-rate to 40 and higher — this sudden change and onset of 
medullary edema occurring within a period of several hours ; the pulse- 
and respiration-rates continued to such a height and irregularity that soon 
the pulse could not be palpated and even the heart-beat became impercept- 
ible, whereas the respiration now faded into a shallowness that it was not 
possible to auscultate ; a pulmonary edema — choking and drowning the 
patient, as it were, in the body fluids — most frequently occurred in heavy 
obese patients, and especially in alcoholics.) 



CHAPTER V 

The Signs of Intracranial Pressure Observable in the Fundus with 

the Ophthalmoscope 

The fundus of the eye, and particularly the retina, being an offshoot 
of the brain, is most intimately connected with the brain and the intradural 
cavity, so that any lesion within the intracranial cavity which increases its 
normal content would naturally tend to be shown in the fundus of the eye, 
especially about the optic nerve head; that is, unless the normally free 
communication within the vaginal sheath between the intradural cavity 
and the optic papilla is obstructed by local disease, adhesions, etc., we should 
expect the signs of increased intracranial pressure to be observable in the 
fundus of the eye, particularly about the optic disk. Again, an increased 
intracranial pressure sufficient to retard and even prevent the normal return 
flow of blood in the retinal veins would also tend to cause a dilatation of 
these retinal veins and the usual condition resulting from their dilatation 
and congestion. 

The effect of an increase of intracranial pressure upon the fundus of the 
eye can be very easily demonstrated in its various stages by the experimental 
production of an internal hydrocephalus in dogs. Three years ago, the con- 
dition of hydrocephalus was successfully produced by me in nine puppies of 
the age of ten days to two weeks; by means of a suboccipital exposure, a 
small gelatine capsule filled with cotton was inserted into the aqueduct of 
Sylvius so that the cerebrospinal fluid could not escape from the third 
and lateral ventricles ; a resulting internal hydrocephalus with dilatation of 
the ventricles, and therefore an increased intracranial pressure, occurred, 
so that it was possible with the ophthalmoscope to observe the changes in 
the fundus of the eye due to this increase of intracranial pressure. Within 
five or six hours after the insertion of the cotton plug into the aqueduct 
of Sylvius, in each one of the puppies the retinal veins gradually became 
dilated; apparently the veins over the nasal half enlarged earlier and 
possibly more than the veins over the temporal half of the retinal fundus. 
This congestion and dilatation of the retinal veins was the first sign indica- 
tive of an increase in the intracranial pressure. Within two to four hours 
later, the nasal margin of the optic disk would become blurred, then the 
temporal margin, then the nasal half and finally the temporal half of the 
disk would become obscured, so that within a period of twelve to twenty- 
eight hours following the production of a definite increase of intracranial 
pressure, the details of the optic disks could no longer be observed ; in four 
dogs the edema of the optic disks was so great within this period of time 
that a measurable swelling could be observed with the ophthalmoscope and 
thus the designation of "choked disks" could be applied; in the other five 
dogs, the measurable papilledema occurred from twelve to twenty hours 
later. In one dog this condition of internal hydrocephalus with high 
intracranial pressure was not relieved by a subsequent drainage operation, 
54 






THE SIGNS OF INTRACRANIAL PRESSURE 55 

and it is interesting to note that definite signs of a secondary optic atrophy 
began to appear nine weeks later ; the remaining eight dogs were all drained 
through a subtemporal operation with six linen strands being inserted into 
the ventricle in order to relieve the condition of internal hydrocephalus; 
in all but three of the dogs the increased intracranial pressure was relieved, 
and it was most interesting to note that the subsidence of the choked disks 
was in just the reverse order of their occurrence — that is, the measurable 
swelling of the papilledema first disappeared, then the blurring of the 
temporal half and then of the nasal half of the optic disk; then the tem- 
poral margin and later the nasal margin appeared — though slightly blurred 
in all of the puppies ; that is, the persistent dilatation of the retinal veins 
and some blurring of the nasal margins of the optic disks indicated that 
the intracranial pressure had not been entirely relieved by the operation. 
In the remaining three puppies the optic disks remained entirely obscured — 
only the measurable swelling disappeared, so that in these dogs the opera- 
tion of drainage to relieve the condition of internal hydrocephalus was 
not successful. 

This experimental work has been most instructive regarding the 
mechanical factor in the production of papilledema and the condition known 
as "choked disks." There exists at present much confusion in the termi- 
nology of retinal conditions, especially in their relation to intracranial pres- 
sure ; the terms papillitis and papilledema have been used interchangeably, 
and "choked disk" most freely and carelessly. Naturally, the terms 
papillitis, retinitis, and optic neuritis imply a condition of inflammation 
of the nerve head and the retina. Inflammation (in its modern conception) 
is due to toxic and infective causes alone, so that in the condition of 
nephritis, diabetes, and the various forms of meningitis, the term papillitis 
would indicate a retinal change due to some toxic or infective cause, whereas 
the blurring and edema of the details of the optic disk due to an increase 
of intracranial pressure in purely mechanical conditions, such as an intra- 
cranial tumor mass and hemorrhage, could be termed as a papilledema ; and 
if a measurable edema, then a swelling of the disk up to the stage of 
i ' choked disk. ' ' In order that a choked disk occur, it must always be pre- 
ceded by a series of blurring of the details of the optic disk, so that these 
early edematous blurrings of the optic disks have been termed the mild 
or early stages cf papilledema or even a "choking" of the disks. If it is 
believed that intracranial pressure alone does cause in the fundus of the eye 
an inflammation (using the term "inflammation" in its modern sense 
as being due to a toxic or infective cause) , then the term papillitis is perfectly 
proper, although the etiological factor in its production is pressure : but I do 
feel that the modern methods of examination of the cerebrospinal fluid, and 
especially its cell count, whereby any inflammation and infectious condition 
within the cerebrospinal canal and also its projecting connections, such 
as the optic vaginal sheath, can easily be demonstrated. — that these methods 
should disclose the infective character of the cerebrospinal fluid if that is a 
cause of the so-called papillitis in the purely pressure eases. Tt has been 
frequently demonstrated in the body tissues and elsewhere that pressure 
can and does cause congestion and edema, but not inflammation (in its 



56 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

modern sense), unless infection is present; pressure upon tissue renders 
that tissue more susceptible to inflammation by infection — a predisposing 
cause — but pressure in itself does not mean an inflammation. It is rather 
rare for retinal hemorrhages to occur in cases of ' ' choked disks ' ' due to even 
extreme intracranial pressure alone, whereas in conditions of neuro-retinitis, 
optic neuritis, and papillitis due to toxic causes such as diabetes and 
nephritis — these hemorrhages occur very frequently. However, if we must 
take it for granted that the retinal and optic disk changes in conditions of 
intracranial pressure are due to both pressure and toxic factors — possibly 
the pressure producing the toxic appearance of inflammation — then the 
condition of blurring and edema of the details of the optic disks would 
precede the stage of papillitis; and if the papilledema became measurable 
to two or more diopters, then the term " choked disks" should be applied. 
In discussing the pressure signs observable in the fundus in the following 
intracranial conditions, I shall use the terms blurring and edema of the 
details of the optic disks to indicate the earlier stages of increased intra^ 
cranial pressure, and its later stages of measurable swelling of the optic disks 
by papilledema, and the term "choked disks" in the conditions of extreme 
intracranial pressure where the papilledema is greater than two or three 
diopters. These signs of increased, intracranial pressure as exhibited upon 
the fundus of the eye have been checked up and confirmed by a measure- 
ment of the pressure of the cerebrospinal fluid at lumbar puncture by 
means of a spinal mercurial manometer, so that when there is observed a 
blurring or edema of the margin of the nasal half of the optic disk in a 
patient following a cranial injury, or in a patient in whom a brain tumor or 
brain abscess is feared, or in a baby following a difficult labor and convul- 
sions occur so that an intracranial hemorrhage is suspected, then it is very 
important to record accurately the pressure of the cerebrospinal fluid at 
lumbar puncture; if the pressure of the cerebrospinal fluid, too, is shown 
to be increased and thus the ophthalmoscopic findings are confirmed, we can 
then reach a more accurate diagnosis of the intracranial condition and 
advise accordingly. Naturally, in normal fundi, blurring and mild obscura- 
tion of the details of the optic disks occur and are considered as being within 
physiological limits; especially is this true in myopia, but if this obscuration 
of the details of the optic disks is observed and then the measurement of the 
cerebrospinal fluid is performed at lumbar puncture by means of a spinal 
mercurial manometer (the most accurate method now known to record the 
pressure of the cerebrospinal fluid), we are thus enabled to exclude those 
cases of so-called normal blurring of the optic disks. 

There are several intracranial conditions that frequently produce definite 
pressure signs observable in the fundus of the eye. In order to understand 
thoroughly and to appreciate the significance of the various degrees of intra- 
cranial pressure as revealed in the fundi, the ophthalmoscopic findings of 
the following intracranial conditions are discussed briefly and in this order : 
brain tumor, brain abscess, hydrocephalus, selected cases of cerebral spastic 
paralysis due to an intracranial hemorrhage at the time of birth, and 
lastly an intracranial hemorrhage and cerebral edema following brain injur- 
ies with and without fracture of the skull. 



THE SIGNS OF INTRACRANIAL PRESSURE 57 

I. Brain Tumor. — The condition of "choked disk," and, if not relieved, 
its subsequent secondary optic atrophy, is well known in patients having the 
signs of intracranial tumor. Naturally, for a "choked disk" to occur, there 
must be a very high intracranial pressure, and I believe it is rare in cases 
of brain tumor for a ' ' choked disk ' ' to result unless the tumor has become of 
very large size, or it causes a blockage of the ventricles, and thus produces 
an internal hydrocephalus, such as the posterior mid-brain tumors and 
the subtentorial tumors and cysts. It is comparatively easy to make the 
diagnosis of brain tumor at this stage of papilledema, and I feel that if these 
patients had been examined ophthalmoscopically early, then the more mild 
pressure signs observable in the fundus resulting from the smaller tumor 
mass would have been ascertained and the patient thus spared an impaired 
vision, if not blindness itself. The stage of ' ' choked disk" must naturally be 
preceded by the earlier and milder stages of disk blurring and papilledema, 
and should therefore be recognized as being more significant than being 
within physiological limits. Only too frequently the surgically successful 
removal of the brain tumor is possible, and yet the patient has already been 
irreparably damaged by the non-recognition of its pressure signs until it is 
too late for a normal person to be obtained. An interesting syndrome 
ophthalmoscopically is that of certain frontal tumors, which may in their 
growth by direct pressure down upon the ipsolateral optic nerve produce 
a primary optic atrophy, and as the result of the increased intracranial 
pressure there is observed in the opposite fundus a * ' choked disk ' ' — the fore- 
runner of a secondary optic atrophy. 

II. In brain abscess, there is a replacement and substitution of cerebral 
tissue by the purulent detritus, and thus, as in gliomatous tumors which infil- 
trate and replace brain tissue rather than push it aside, it is rare for the 
definite signs of intracranial pressure to be observed in these patients unless, 
as has been stated before, the ventricles are blocked, or a toxic and infective 
meningitis occurs from the presence of the abscess. This ventricular block- 
age is of frequent occurrence in subtentorial and cerebellar abscess, but it is 
rare for an abscess of the temporo-sphenoidal lobe, which is the most common 
location of brain abscess following the usual cause — an otitis media — to 
produce fundal changes even though the abscess may reach the size of an 
orange and even larger. 1 

III. Hydrocephalus. — The ophthalmoscopic findings in the cases of 
hydrocephalus — whether it is of the internal type due to a blockage of 
the cerebrospinal fluid in the ventricles and thus producing ventricular 
dilatation and its resulting extreme intracranial pressure, or of the external 
type of hydrocephalus which is due to a partial blockage of the escape of the 
cerebrospinal fluid from the general cerebrospinal canal. This latter con- 
dition rarely causes a measurable papilledema, whereas the internal type 
of hydrocephalus can produce "choked disks" of extreme degree and their 
subsequent secondary optic atrophy. Fortunately in little babies before 
the sutures have firmly united, the skull itself can enlarge, and thus in 
many of these patients a natural compensatory "decompression" takes place 
so that the peripheral vision may not be impaired: a drainage operation. 

1 The Laryngoscope, March, 1914. 



58 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

however, offers these children their best chance of approximating normality. 2 
IV. Selected cases of cerebral spastic paralysis due to an intracranial 
hemorrhage at birth. — In these patients, the ophthalmoscopic examination 
is of very great importance in aiding the differentiation of this type of 
intracranial lesion from the other causes of cerebral spastic paralysis. It 
is very interesting to note that Mr. W. J. Little, in his first monograph in 
1843 upon spastic paralysis, entitled "Deformities of the Human Frame," 3 
or the now so-called Little's disease, stated that the condition was due to 
an impairment of nerve tissues resulting from their lack of development 
and also to an earlier meningitis; a few cases, however, followed difficult 
labors, and undoubtedly these were, in his opinion, due to an intracranial 
hemorrhage at birth. In 1862 (nineteen years later) , in his second monograph 
upon spastic paralysis, entitled ' ' On the Influence of Abnormal Parturition, 
Difficult Labors, etc., upon the Mental and Physical Condition of the 
Child," 4 he says that, in his opinion, almost 75 per cent, of these cases are 
due to intracranial hemorrhage. Recent investigation of this condition also 
confirms this belief that about three-fourths of these cases are due to intra- 
cranial hemorrhage at the time of birth. 

In order to differentiate the three chief causes of cerebral spastic 
paralysis in children — that is, first, a lack of development of the cerebral 
cortex or its pyramidal tracts ; secondly, a meningitis and meningo-encepha- 
litis following the infectious diseases such as cerebrospinal meningitis, 
measles, scarlet fever and whooping-cough; and lastly, an intracranial 
hemorrhage, it is very important that a careful ophthalmoscopic examination 
should be made as early as possible. The measurement of the pressure of the 
cerebrospinal fluid at lumbar puncture with the spinal mercurial manometer 
should also be used to confirm the fundal findings of increased intracranial 
pressure. Naturally, in cases of lack of development of cerebral tissues 
there can be no increase of the intracranial pressure, and this is also true 
of those patients who have survived a meningo-encephalitis — a destruc- 
tion and atrophy of cortical nerve tissue. On the contrary, if an intracranial 
hemorrhage has occurred, then there should be signs of an increased intra- 
cranial pressure as a result of the hemorrhage, as shown by a dilatation 
of the retinal veins and an edematous blurring of varying degree of the optic 
disks. Naturally, the earlier this examination is made the more definite 
are the fundal signs of intracranial pressure, whereas in the older children 
the ophthalmoscopic examination may reveal only a dilatation of the retinal 
veins with thickened walls from new tissue formation and a shallow disk 
cup; the disk itself is blurred in its details, particularly along the nasal 
margin, while, the temporal margin, and even the nasal half of the disk, 
may be obscured. In no patient of over one year of age have I found a 
measurable swelling of the disk to the degree of "choked disk." Upon 
examining a patient having cerebral spastic paralysis, if the above fundal 
changes are noted, then the pressure of the cerebrospinal fluid should be 
measured at lumbar puncture in order to ascertain whether the fundal 

2 American Journal of Medical Science, April, 1917. 

3 The Lancet, vol. i, p. 350, December 16, 1843. 

4 Obstetrical Transactions, vol. iii, p. 293, 1862. 



THE SIGNS OF INTRACRANIAL PRESSURE 59 

changes are due to a local condition within the orbit or are possibly within 
the normal physiological limits. In these children within one week after 
birth, there is usually blood in the cerebrospinal fluid at lumbar puncture, 
as was demonstrated in 21 children upon whom I operated within three 
days after birth. 

In a report 5 of 954 cases of cerebral spastic paralysis up to April 1, 
1916, only 26 per cent, of them — that is, only one out of every four patients 
examined — showed these definite signs of an increased intracranial pressure, 
and the spastic condition was therefore due to a hemorrhage, and in these 
selected patients by a cranial operation to relieve this increased intracranial 
pressure upon the brain, an improvement was to be obtained. At that time. 
I had operated upon 219 children with a mortality of 16 — that is, 8 per 
cent. The history of these children is very suggestive : of the 219 operated 
patients, only 26 were not first children ; only 8 were not full-term babies ; 
only 21 were not born after a difficult labor, with or without instruments ; 
only 49 did not have convulsive twitchings immediately after birth; and 
in only 21 children was the spasticity noticed before the eighth month after 
birth. A permission for autopsy is obtained before operation in each 
patient, both private and ward, and it is by this valuable means, as well 
as by the operative findings, that the diagnosis is verified and other 
data ascertained. 

V. Intracranial hemorrhage and cereoral edema following brain injur- 
ies, with and without a fracture of the skull, rarely produce a measurable 
papilledema to the extent of ' ' choked disks. ' ' The reason for this is obvious : 
unlike brain tumor, hydrocephalus, and the other intracranial conditions 
which enlarge slowly and thus permit the brain and particularly the 
medulla to adapt themselves to this increased pressure with little immediate 
risk, in many cases of traumatic intracranial hemorrhage and cerebral 
edema, in the absence of marked shock, the intracranial pressure rises most 
rapidly, so that the compensatory mechanism of the medulla has little time 
to adjust its vasomotor and respiratory centres to this increased pressure, 
and the result in these patients is death even before the development of 
" choked disks" is possible. If these patients could survive this greatly 
increased and rapidly produced intracranial pressure, then a measurable 
papilledema and "choked disks" would occur. In brain injuries with and 
without a fracture of the skull, "choked disks" do occur in the cases of large 
hemorrhage following a rupture of the middle meningeal artery. In these 
cases of intracranial pressure of comparatively slow production, the medulla 
can adapt itself to the pressure, and thus death does not occur before a meas- 
urable papilledema and "choked disks"' are possible. I have operated upon 
a number of these patients; the "choked disks" of two or more diopters 
developed within several days after the brain injury; at the operation of 
subtemporal decompression, either an extradural hemorrhage, alone or 
associated with a subdural hemorrhage of large amount, was removed 
The subsidence of the measurable papilledema began immediately after the 
operative drainage of the intracranial pressure, so that within 24 hours there 

5 New York State Journal of Medicine, October, 1010. 



6o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

were present only an edema and blurring of all the details of the optic disks 
but not a measurable swelling of the disks themselves. 

It is most rare in these cases of brain injuries with and without a 
fracture of the skull for an edema of the optic disks to appear within six 
hours following the trauma, and particularly is this true of tho£3 patients 
in the various degrees of shock; the greater the shock the less the general 
blood-pressure, and naturally, even though a large intracranial sinus or 
vessel was torn, yet it would be difficult for any extensive hemorrhage to 
occur. Just as soon as the intracranial pressure equalled this lowered 
blood-pressure of shock, then no more bleeding could occur because the 
intracranial pressure would now be equal and even higher than the blood- 
pressure ; as the patient rallied from the condition of shock, then naturally 
the blood-pressure would become higher and then more intracranial bleeding 
would occur, and thus the signs of intracranial pressure, such as edema 
of the optic disk outlines, would now be possible. In these patients, the 
marked signs of shock usually last about four to six hours; and again, 
those patients who cannot survive the condition of shock — they die within 
six hours after the injury. 

In these cases of brain injury it is of little or no importance in the 
treatment to know the site and extent of the fracture, whether it is a vault 
or basal fracture, but it is of the utmost importance to ascertain the presence 
or not of an increased intracranial pressure, both by careful and repeated 
ophthalmoscopic examinations, and also by the measurement of the pressure 
of the cerebrospinal fluid at lumbar puncture by means of the spinal mer- 
curial manometer. If there are definite signs of a marked increase of the 
intracranial pressure, such as an edematous blurring of the details of the 
optic disks and twice the normal pressure of the cerebrospinal fluid and 
even more, whether the medullary compression signs of a lowered pulse-rate 
and Cheyne-Stokes respiration are present or not, then I believe an early 
relief of this increased intracranial pressure by means of a simple subtem- 
poral decompression and drainage is advisable before the patient reaches 
the dangerous stage of extreme medullary compression and even edema, 
and thus the collapse of the medulla itself. If an operation is postponed in 
these patients until a "choked disk" occurs, then the ideal time for operation 
will have been lost, and it is then very doubtful whether the patient will 
recover; besides, should the patient having had high intracranial pressure 
recover without an operation or at best a very late operation, then the 
danger of post-traumatic conditions is very great indeed. These conditions, 
due to a prolonged increase of the intracranial pressure, are persistent head- 
ache, an emotional instability of either the excited or the depressed type, 
mental and physical lassitude and early fatigue, and in rare cases even epi- 
lepsy in its various forms. It is evident, therefore, in patients having 
cranial injuries, that it is most important to establish the presence or absence 
of an increased intracranial pressure — it matters not whether that pressure 
is or is not due to hemorrhage or cerebral edema — and that repeated 
ophthalmoscopic examinations are of the greatest aid in facilitating an 
accurate diagnosis and the early treatment of the condition. Besides the 
conditions already mentioned, there are still other intracranial lesions in 



THE SIGNS OF INTRACRANIAL PRESSURE 61 

which an ophthalmoscopic examination is of the greatest importance: in 
cases of the various forms of meningitis, as an aid in differentiating the 
types of apoplexy, and a most important function in so many conditions — 
the presence of a negative fundus. 

In view of these considerations, therefore, it is essential that careful and 
repeated ophthalmoscopic examinations of the fundi be made, as they are 
of the greatest importance in the differentiation of many intracranial 
lesions ; that the signs of moderate intracranial pressure should be recog- 
nized, and that it should be realized that ' ' choked disks ' ' occur only as an 
advanced result of high and prolonged intracranial pressure, and rarely 
in patients having brain injuries ; that the measurement of the pressure of 
the cerebrospinal fluid at lumbar puncture by means of the spinal mercurial 
manometer is the most accurate means of determining the intradural pres- 
sure ; and lastly, the intelligent use of the ophthalmoscope, especially the 
direct method, should be much more intensively studied in the medical 
schools and in the hospitals than it is at present. 



CHAPTER VI 

Intracranial Pressure as Measured by the Spinal Mercurial 
Manometer at Lumbar Puncture 

Until three years ago the ophthalmoscopic examination was considered 
the most satisfactory method of determining the presence or not of, and 
the degree of, an increased intracranial pressure; during the past three 
years the significance of the pressure of the cerebrospinal fluid and its accu- 
rate registration by means of the spinal mercurial manometer have been 
so developed that the ophthalmoscopic findings, unless the increased intra- 
cranial pressure is of sufficient degree to produce the condition of ' ' choked 
disks" (a rare observation in these patients having brain injuries), are 
merely indicative of intracranial pressure, whereas the findings of the spinal 
mercurial manometer are not only confirmatory, but the degree of increased 
intracranial pressure can be most accurately established. The most prac- 
tical of these instruments is the one devised by Landon ; it is similar to a 
blood-pressure apparatus (Fig. 15) and there is no risk to the patient other 
than that of a lumbar puncture which is practically nil when properly 
performed. It is essential for an accurate measurement of the pressure that 
the patient should be lying quietly upon his side with the median line of 
the head upon an exact level with the spinal canal. (If the physician is 
right-handed, then it facilitates the insertion of the puncture needle if the 
patient lies upon the left side.) The thighs and knees should be flexed upon 
the chest with the head and neck bent forward so that the knees almost touch 
the head ; an assistant facing the patient and putting his right arm about 
the patient's neck and his left arm under both knees can easily approximate 
these parts and at the same time hold the back of the patient at the edge of 
the bed and at right angles to it ; in the manner of forcibly l ' arching ' ' the 
lumbar region, the spinous processes are diverged, the intervertebral spaces 
widened and thus the insertion of the puncture needle is not a difficult one ; 
either the mid-line may be used so that the needle is thrust directly at 
right-angles into the spinal canal, or if it is desired to avoid the interspinous 
ligaments, then the needle may be inserted just below and lateral to the 
mid-line (1 cm.) and then slightly obliquely upward until it enters the 
spinal canal. (In very muscular adults the latter method of insertion may 
be advisable, but it is not necessary and particularly in children; I have 
never seen any ill-effects from a lumbar puncture in the mid-line, and it 
really makes little difference which route is used ; at times owing to abnormal 
bony conformation or in patients whose backs cannot be satisfactorily 
" arched," then the performance of a successful puncture may be most 
difficult: either route may be used, and a number of attempts may be 
necessary before the spinal canal is entered; it is exceedingly rare, how- 
ever, for a lumbar puncture not to be possible in these traumatic patients.) 
A general anesthetic is never necessary, and it is only in the occasional 
patient that even local anesthesia is advisable — the effect being more of a 
psychic one than a lessening of the skin prick, which is, in reality, little more 
62 



SPINAL MERCURIAL MANOMETER AT LUMBAR PUNCTURE 63 

painful in this area of the back than the pulling of a hair or a pinch of the 
skin ; if, however, a local anesthetic must be utilized, then the freezing appli- 
cation of ethyl-chloride can be used or a weak novocaine solution — and, of 
almost equal value for these patients, merely sterile water hypodermically ; 
in babies and children, any procedure of local anesthesia, and especially 
hypodermically, is more terrifying to the patient than the puncture itself, so 
that local anesthesia for lumbar puncture is never willingly advised. 

The site of election for the lumbar puncture is the fourth lumbar inter- 
space — almost on a level with the crest of the iliac bones ; at times the verte- 
bral interspace between the third and fourth spinous processes is a more 
satisfactory approach to the spinal canal, but a lumbar puncture should not 
be made between the second and third lumbar vertebras, for fear of injuring 
the terminal portion and filaments of the spinal cord, which may be ab- 
normally low; in children and babies, especially, the puncture should be 




Fig. 15. — The Spinal Mercurial Manometer, consisting of a U-shaped tube containing mercury to 
the level of zero on the registered scale of cubic millimetres; the lumbar puncture needle, after the with- 
drawal of its stylet, has been connected with the rubber tubing. of one arm of the mercurial tube. The 
necessary equipment of a small piece of sterile cotton or gauze and tincture of iodine for the asepsis, and 
whenever advisable for local anesthesia the solution of ethyl chloride or a weak novocaine mixture. 

limited to the fourth lumbar interspace between the fourth and fifth spinous 
processes as the end of the spinal cord may be as low as the fourth lumbar 
vertebra before it makes its normal ascent as the child grows older to 
become stationary at about the middle of the second vertebra. 

During the past three years, the following technic has been used in 
over eleven hundred lumbar punctures ; the patient lying upon his left side 
and being "doubled up" by an assistant, so that the back was "arched'' 
by the knees being approximated to the head, a small area of the spine, about 
one silver dollar in size, is painted with iodine solution, between the fourth 
and fifth spinous processes — roughly on a level with the iliac crests (Fig. 16) , 
The operator 's right thumb and forefinger may be also painted with iodine 
to minimize the risk of infection in handling the puncture needle, and yet 
this is not necessary, as the point and shaft of the needle should never bo 
touched, and it is thus possible to insert the puncture needle without touch- 
ing any portion of it other than the hilt, (This care in not touching the 
point and shaft of the puncture needle is a much safer precaution than the 



64 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

use of sterile gloves for hands which are not surgically cleansed ; the operator 
may thus consider himself "clean," the puncture needle be handled care- 
lessly and the possibility of an infection greatly increased. Sterile gloves 
in themselves do not render the hands sterile, and if they are used, then the 
hands should be scrubbed with green soap and water and made surgically 
clean in the routine manner. ) It is usually possible to know when the punc- 
ture needle reaches and passes through the dura, owing to the slightly 
increased resistance to the point of the needle ; the stylet is now withdrawn 




Fig. 16. — The lumbar puncture needle inserted into the spinal canal and connected with the manom- 
eter; the spinal pressure registers in this patient a height of 12 mm. of mercury. The patient is lying 
quietly upon the left side — the median line of the head being upon a level with the spinal canal. The 
skin over the area of the insertion of the needle, between the 4th and 5th lumbar vertebrae, has been painted 
with iodine for the asepsis. 

— great care being used not to touch its point or shaft or to lay it down, 
and in this manner, if the cerebrospinal fluid does not flow from the needle, 
then the stylet may be replaced safely and the puncture needle inserted 
farther or moved gently up and down and laterally until the fluid appears 
at its lumen; it is possible at times for a small piece of tissue or a nerve 
filament of the cauda equina to block the inner lumen of the needle by 
the suction of the cerebrospinal fluid as it begins to flow through the 
needle, and in this manner the cerebrospinal fluid is prevented from 
escaping ; gently moving the needle, however, usually suffices to remove this 
blockage. If one of the plexus of veins within the spinal canal is penetrated, 
blood may escape from the needle and continue to flow until the needle is 



SPINAL MERCURIAL MANOMETER AT LUMBAR PUNCTURE 65 

blocked; it is usually wiser to attempt another puncture by withdrawing 
the needle, not out from the skin, but only from the dural sac and then re- 
inserting it at another point ; very frequently clear cerebrospinal fluid may 
thus be obtained. In some cases, however, when it is doubtful whether there 
is really free blood in the cerebrospinal fluid or not, it is usually wiser to 
perform another lumbar puncture several hours later. The important 
observation to be obtained in these traumatic patients, however, is the pres- 
ence or not of a marked increase of the intracranial pressure and the appear- 
ance of free blood in the cerebrospinal fluid is really of little importance — ■ 
especially in so far as the treatment of the patient is concerned. 

The dural sac having been pierced by the puncture needle, the stylet 
is now withdrawn and the stop-cock turned so that the cerebrospinal fluid 
can flow into the sterilized rubber tubing connecting the puncture needle 
with the mercurial U-tube of the spinal manometer. With the patient lying 
perfectly quiet, the median line of. the head being upon a level with the 
spinal canal, and the zero reading of the mercury of the manometer at a 
level with the spinal canal, the pressure of the cerebrospinal fluid can now 
be registered — the lowest level of fluctuation of the mercury being con- 
sidered the pressure. If the patient is perfectly quiet with normal regular 
respiration, then there is practically no corresponding rise and fall of the 
mercury reading, but if the patient should be struggling or crying, as in 
children, then the reading of the manometer should not be recorded until 
the patient is as quiet as possible — and then the lowest level of the mer- 
cury considered as representing the approximate pressure of the cerebro- 
spinal fluid. Under a general anesthetic, if the patient is not perfectly quiet 
and breathing normally, the pressure of the cerebrospinal fluid as regis- 
tered by the spinal mercurial manometer may be increased 2-5 mm., and this 
should be deducted from the lowest reading of the mercurial level. 

The normal pressure of the cerebrospinal fluid as registered at lumbar 
puncture by the spinal mercurial manometer varies from 5-9 mm. in adults 
and 4—8 mm. in children (approximately 16-30 drops per minute) ; 1 or 2 
mm. has been obtained in patients in severe shock, and frequently in chil- 
dren having an agenesis or lack of development of the brain associated or 
not with the condition of microcephalus. 

After the pressure of the cerebrospinal fluid has been accurately re- 
corded, if it is desired (and it usually is) to remove a small quantity of the 
fluid for examination (Wassermann test, cell count, globulin content and 
colloidal gold reaction), then the rubber tube can be easily detached from 
the manometer and the cerebrospinal fluid allowed to flow slowly into one or 
more sterile test-tubes. Not more than 5 c.c. should, as a rule, be withdrawn 
— and particularly is this true in patients having a very high pressure due 
to intracranial tumor formation or large intracranial hemorrhage ; the danger 
of the medulla being forced down into the foramen magnum and directly 
compressed and " collared," as it were, by the sudden lowering of the 
pressure of the spinal canal should always be remembered ; this risk is slight 
and never occurs if the lumbar puncture is properly performed — that is. 
not more than 5 c.c. being removed (and no larger quantity is ever neces- 
sary to be withdrawn for examination) and the fluid being permitted to 



66 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

escape very slowly and not rapidly in spurts; firm compression upon the 
rubber tube easily regulates the rate of flow. When these two precautions 
are observed these medullary complications never occur as a result of 
lumbar puncture ; during* the past seven years in this department and clinic, 
over 1600 lumbar punctures were performed, and in only three patients did 
this medullary complication happen, and in each case the lumbar puncture 
was performed by an inexperienced interne who held the erroneous belief 
that the purpose of the puncture was to remove as much of the cerebrospinal 
fluid as possible and in this manner lower the extreme intracranial pres- 
sure; two of these patients had an intracranial tumor (one being subten- 
torial) and the third patient having the condition of internal hydrocephalus ; 
each of these patients died within six hours after the lumbar puncture from 
the signs of acute medullary compression and an autopsy revealed in each 
case the direct medullary compression of the surrounding collar of the 
foramen magnum, and thus constricting the medulla in its middle portion ; 
upon post-mortem hardening the medulla in situ, the characteristic furrow 
and groove of the compressed rim of the foramen magnum was easily demon- 
strable. If subtentorial lesions are excluded and the intracranial pressure 
is not high, then there is little or no danger in allowing a large quantity 
of cerebrospinal fluid to escape ; this is not necessary nor advisable for 
diagnostic purposes, and it is only as a therapeutic measure in mild cases of 
cerebral edema ("wet" brain) following brain injuries and toxic and infec- 
tious conditions, such as chorea, delirium tremens, uremia and diabetic 
cases and in the preliminary stages of meningitis and meningeal irritation 
(meningismus) ; in these conditions, frequently repeated lumbar punctures 
with the removal of a larger quantity of cerebrospinal fluid each time will 
usually lessen, if only temporarily, the severity of the intracranial symptoms 
and signs and may thus facilitate the recovery of the patient. The value of 
these therapeutic lumbar punctures, however, has not definitely been 
established in these conditions, since the number of cases reported is com- 
paratively small and not conclusive. 

Upon withdrawing the puncture needle, the area of skin painted with 
iodine solution is rubbed with alcohol and a small sterile gauze pad applied 
and held in place by two small strips of adhesive plaster. It is usually 
advisable for ambulatory adult patients to remain in bed for at least twelve 
hours following the lumbar puncture ; naturally, patients having acute brain 
injuries are confined to their bed, but it is not very exceptional for them to 
be walking about or to be desirous of even being out of bed. In children, 
however, unless the intracranial condition is an acute one, it is not so 
essential for them to remain in bed longer than several hours at most. The 
ideal time for performing the test is at night, so that the patient may sleep 
as usual and by morning any symptomatic effects of the puncture 
have usually disappeared. 

The headache of greater or less severity which may follow a lumbar 
puncture usually occurs in the presence of an increased intracranial pres- 
sure and when more than 5 c.c. of the cerebrospinal fluid have been rapidly 
removed, and only occasionally if no fluid or, at most, less than 5 c.c. 
have been carefully and slowly withdrawn. It does, however, occur at 



H 



SPINAL MERCURIAL MANOMETER AT LUMBAR PUNCTURE 67 

times even when no fluid has been allowed to escape and when the puncture 
was made merely to estimate the degree of pressure ; the various explanations 
for this so-called ' ' lumbar puncture headache ' ' are not entirely satisfactory ; 
whether it results from a meningeal irritation, an intracranial circulatory 
disturbance, a temporary increase of the secretion of the cerebrospinal 
fluid or a continued leakage of the fluid through the puncture opening of 
the spinal dura (McRoberts) , and thus tending to produce a ' ' dry" condition 
of the brain and to permit its! resting upon the base of the skull, is not 
definitely known. 

The purpose of the lumbar puncture is two-fold : first, as an aid in the 
diagnosis of the cerebrospinal lesion, and second, as a therapeutic measure 
in selected conditions affecting the cerebrospinal system. As a diagnostic 
aid the lumbar puncture makes it possible for the pressure of the cerebro- 
spinal fluid to be recorded accurately by the spinal mercurial manometer, 
and thus the degree of intracranial pressure be ascertained for numerous 
lesions, and a small quantity of the fluid itself can also be removed at the 
same time for the various laboratory tests, such as the Wassermann (luetic 
infections), cell count (acute and chronic infectious and inflammatory 
conditions), globulin content (tumor formations), colloidal gold reaction 
(paresis), etc. It is important to ascertain the degree of increased intra- 
cranial pressure in the following conditions, in order that the approximate 
treatment be instituted as early as possible : acute and chronic brain injuries 
in adults, children and new-born babies, suspected intracranial tumors, 
hydrocephalus of either the internal or the external type, and the numerous 
toxic and infectious cerebrospinal conditions, especially meningitis in its 
various forms, and the severe type of cerebral edema occurring in uremia, 
diabetes and alcoholism. 

The therapeutic value of repeated lumbar punctures and removal of 
varying amounts of the cerebrospinal fluid in intracranial conditions asso- 
ciated with cerebral edema ("wet" brain) has not been definitely estab- 
lished ; in this series of brain injuries, with and without a fracture of the 
skull, there has been a number of patients in whom the intracranial pressure 
has been increased with and without the presence of free blood in the cere- 
brospinal fluid and yet the pressure was not sufficiently high to warrant the 
cranial operation of decompression and drainage ; yet, in order to diminish 
this increased intracranial pressure, lessen the symptoms of headache, dizzi- 
ness and nausea, and the signs of stupor, restlessness, and thus improve the 
general condition of the patient and facilitate an early and complete recov- 
ery, repeated daily lumbar punctures with removal of 15-20 c.c. of cere- 
brospinal fluid were performed, and it was very impressive to observe in 
each of these selected patients an almost immediate improvement ; usually 
lumbar punctures upon four or five successive days were necessary in order 
to lessen the pressure permanently — the patient each time experiencing such 
a marked relief of headache and dizziness that the slight momentary pain of 
the lumbar puncture itself was welcomed because, as the patient so fre- 
quently reiterated, "I feel so much better almost immediately." Tt was 
also interesting and instructive to observe the lowering of the pressure of 
the cerebrospinal fluid which was usually registered before it was permitted 



68 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

to escape, being 12, 14, or even 16 mm. of mercury, and then after with- 
drawing 15-20 c.c. the pressure now might be only 8, 10 or 12 mm., respec- 
tively ; at the same time, the ophthalmoscopic examination before the lumbar 
puncture and revealing dilated retinal veins and an edematous blurring of 
the nasal margins of the optic disks, would frequently, within four hours 
after the puncture and removal of 15-20 c.c. of cerebrospinal fluid, disclose 
almost clear and distinct nasal margins of the optic disks and the retinal 
veins less dilated than before the puncture ; this lessening of the intracranial 
pressure as revealed by the ophthalmoscope rarely continued longer than 
ten or twelve hours, when the retinal veins gradually became more and more 
enlarged while the nasal margins of both optic disks became less distinct 
until they were finally obscured entirely by the edema; at times even the 
temporal margins were blurred for several hours as though the removal of 
the cerebrospinal fluid at lumbar puncture had temporarily at least resulted 
in an increase of the intracranial pressure by stimulating the secretion of 
the cerebrospinal fluid ; this latter observation, however, was made in only 
a small number of the patients. This method of lessening the increased 
intracranial pressure following brain injuries should, however, only be used 
in selected patients, in whom the pressure of the cerebrospinal fluid, as 
revealed by the ophthalmoscope and the spinal mercurial manometer, is 
known to be only mildly increased ; it would be distinctly dangerous as well 
as inadequate for those patients having a high intracranial pressure if more 
than the nasal halves of the optic disks were obscured by edema and the 
spinal mercurial manometer registered a pressure of the cerebrospinal fluid 
being above 16 mm. ; in these patients repeated lumbar punctures and 
removal of large amounts of cerebrospinal fluid might cause an immediate 
medullary compression and even a medullary edema be precipitated as the 
result of direct pressure of the rim of the foramen magnum; as a rule, 
not more than 5 c.c. of cerebrospinal fluid should be removed at lumbar 
puncture for diagnostic purposes and no therapeutic attempt made to 
lessen the intracranial pressure if the ophthalmoscopic and spinal manometric 
tests have disclosed a high intracranial pressure. 

The lumbar puncture is of the greatest diagnostic value as an aid in 
differentiating the various kinds of cerebral spastic paralysis occurring in 
children. It is now definitely established that the condition of cerebral 
spastic paralysis with and without marked mental impairment and com- 
monly known as Little 's disease, is due to one of three causes : first, a lack 
of development of the cerebral tissues, and naturally there can be no increase 
of the intracranial pressure, which is always ascertained to be negative 
by the ophthalmoscopic and spinal manometric tests and therefore not 
amenable to any cranial operative procedure ; secondly, a meningitis and 
meningo-encephalitis — a destructive process of varying degree of the cortical 
nerve cells and not to be benefited by an cranial operative procedure, unless 
the intracranial pressure is markedly increased as a result of a secondary 
external hydrocephalus due to the blockage of the stomata of exit of the 
cerebrospinal fluid, and in these latter selected patients only may the condi- 
tion be improved and the associated convulsions lessened by the operation of 
cranial decompression and drainage ; according to the degree of blockage 



SPINAL MERCURIAL MANOMETER AT LUMBAR PUNCTURE 69 

of the cerebrospinal fluid and therefore of the resulting external hydro- 
cephalus are the signs of an increased intracranial pressure revealed by the 
ophthalmoscopic and spinal manometric tests which, together with the his- 
tory and associated or not with convulsive seizures, form a fairly typical 
picture; those patients in the group due to toxic and infectious conditions 
producing cerebral thrombi and emboli naturally do not cause an increase 
of the intracranial pressure since a localized cerebral atrophy results; and 
lastly, and a most common cause of cerebral spastic paralysis in children is an 
intracranial hemorrhage at or near the time of birth ; the hemorrhage is al- 
most always a supracortical one — rarely within the cortex itself — and thus the 
cortical nerve cells are not destroyed but merely functionally impaired by the 
pressure of the overlying hemorrhage and the development of a secondary 
external hydrocephalus as a result of the blockage of the stomata of exit 
of the cerebrospinal fluid in the cortical veins, sinuses, etc. ; these are the 
patients having an increased intracranial pressure as revealed by the oph- 
thalmoscope and the spinal mercurial manometer, whose history is most 
frequently one of difficult labor at a full-term birth with and without the 
use of instruments and associated or not with convulsive seizures ; they are 
usually first children; unless an early lumbar puncture is performed to 
ascertain the presence of blood and an increased pressure and the true con- 
dition of the brain inju^ recognized, the spasticity of the legs or arms 
may not be observed until the child is seven and even nine months of age ; 
the child is retarded both mentally and physically — does not hold its head 
up nor attempt to sit up or walk until months after it should, and at 'the 
same time the mentality is delayed so that these children become not only 
physically but mentally impaired. The ideal time for the relief of the 
increased intracranial pressure in these patients is as soon as possible after 
birth — when the hemorrhage can be drained in fluid form either by repeated 
lumbar punctures daily or by the cranial decompression and drainage; if 
the true intracranial condition is not recognized within several days after 
birth, then the decompression and drainage should be performed as early 
as possible in order to lessen the cortical compression and thereby permit 
a normal cerebral development both mentally and physically. 



CHAPTER VII 

The Treatment of Brain Injuries with and without a Fracture 

of the Skull 

General Considerations. — For many years, the routine treatment for 
brain injuries, or rather the so-called "fractures of the skull," whether of 
the base or of the vault, has been the expectant palliative one ; that is, an 
ice-bag to the head, vigorous catharsis, liquid diet, and absolute rest and 
quiet, morphia being administered if necessary. Practically all patients 
having fractures of the base were thus treated — it being thought that 
nothing else could be done for such patients; the mortality Avas high — more 
than 50 per cent. Even depressed fractures of the vault, unless there 
were localized signs of cerebral compression, were frequently treated in 
the same manner. 

Naturally, the patients having simple concussion and the mild con- 
ditions of brain injuries with and without a fracture of the skull — and I 
believe that many cases of fracture of the skull are overlooked on account 
of their comparatively trivial symptoms and signs — have been, and are 
being, treated successfully by this expectant palliative method ; it is, how- 
ever, in those patients having brain injuries with and without a fracture 
of the skull, whether of the base or of the vault and with or without a 
depression of fragments, in whom there are marked signs of an increased 
intracranial pressure that this expectant palliative treatment is not suffi- 
cient, and a more effective method of lowering this increased intracranial 
pressure is essential. 

Within the last few years, a notable advance has been made in the 
treatment of these patients. It is not so much a question of ascertaining 
the presence and site of the fracture (unless it is a depressed fracture of the 
vault), but rather of finding out whether there is or is not an increased 
intracranial pressure, and if there is, then directing the treatment toward 
a lowering of this abnormal pressure. For this reason the measurement 
of the pressure of the cerebrospinal fluid at lumbar puncture by means of 
the spinal mercurial manometer should be registered, and also careful 
ophthalmoscopic examinations should be made in each patient in order 
to observe the early signs of an increased intracranial pressure appearing 
in the fundi of the eyes, and especially about the entrance of the optic 
nerve — the so-called optic disk. These changes in the fundi are the result 
of increased intracranial pressure, whether this pressure be due to a slowly 
growing tumor, to an intracranial hemorrhage, or to a very edematous 
"swollen" brain resulting from a brain injury with and without a fracture 
of the skull. It is this cerebral edema, resulting in varying degrees from 
any injury to the brain — from the mild conditions of concussion to the 
worst forms of cerebral contusion and laceration — that has been overlooked 
in the past ; in my opinion, it is the most important factor to be considered in 
any cranial injury. In mild cases, only a slight dilatation of the retinal 
70 



WITH AND WITHOUT A FRACTURE OF THE SKULL 71 

veins results from the intracranial pressure due to this cerebral edema, and 
the veins gradually assume their normal size and appearance within two to 
four days, showing that the intracranial pressure has been lessened as the 
result of the absorption of the edema ; that is, there is present now a more 
normal amount of intracranial cerebrospinal fluid. 

The success of the expectant palliative treatment in these mild cases 
(and they form about two-thirds of the patients having brain injuries) is 
based upon the fact that, by it, not only is the absorption of the cerebro- 
spinal fluid increased, but the amount of cerebrospinal fluid secreted is les- 
sened by the lowering of the blood-pressure and thus the tendency to intra- 
cranial hemorrhage is also lessened. Naturally, the sooner after the injury 
the treatment is started the better are the results to be obtained. 

In the more severe cases, however, a more direct method of lowering this 
increased pressure is necessary; I use the word "severe" not so much in 
reference to the fracture as to the height of the intracranial pressure. These 
are the patients showing not only a dilatation of the retinal veins and an 
edematous obscuration of the nasal margins of the optic disks, but also a 
blurring of the nasal halves of the optic disks and the more advanced signs 
of intracranial pressure to be observed with an ophthalmoscope (although 
it is rare for "choked disks" to be observed in these patients), and the 
spinal mercurial manometer registers the pressure of the cerebrospinal 
fluid above 15 mm. Such patients should have a subtemporal decompres- 
sion and drainage performed to relieve the intracranial pressure as soon 
as possible after the injury. If, however, the patient is in a condition of 
severe shock, so that its signs prevent, overshadow and tend even to conceal 
the signs of intracranial pressure, then all treatment should be directed 
toward relieving the condition of shock, and when this has been accom- 
plished, then the lowering of the intracranial pressure can be considered ; it 
is neither wise nor good surgical judgment to decompress a patient having 
a brain injury and that patient is in severe shock, with a pulse-rate of 110 
or more ; if the patient is unable to survive the shock, surely no operation 
will aid him but will be merely an added shock. The operation itself is not 
a formidable one ; naturally, perfect asepsis is essential. The anesthetic 
should be administered by an expert; only too frequently, however, the 
patient is unconscious, so that an anesthetic is not required. 

Palliative versus Operative Treatment. — In too many hospitals the 
attitude toward patients having brain injuries and the so-called "fractures 
of the skull," and especially those of the base, has been one of expectancy, 
a policy of ' ' letting well enough alone ' ' ; unless there was a marked depressed 
fracture of the vault and the signs of local cortical compression, then the 
usual treatment of these patients was an ice-bag to the head, catharsis, 
absolute rest and quiet, and the general routine expectant palliative treat- 
ment was administered; any operative procedure was not to be considered 
unless the patient developed signs of compression of the medulla — slow 
pulse of 50 and lower, irregular respiration of the Oheyne-Stokes typo and 
a blood-pressure of 170 and higher. Then and only then would an opera- 
tion be advised and performed, and with the usual result — the death of the 
patient. Several days may elapse before the signs of extreme medullary 



72 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

compression occur, but once the later signs of medullary edema and collapse 
do appear, then a cranial operation will be of no benefit unless to possibly 
1 per cent, of the patients — the others all die, operation or no operation. 
The time for the operation of decompression and drainage should be judged 
according to the general condition of the patient and the amount of intra- 
cranial pressure, as shown by the ophthalmoscope and the spinal mercurial 
manometer, and not by the extreme signs of medullary compression, such 
as a very low pulse- and respiration-rate and a high blood-pressure. The 
old method of not operating until definite signs of medullary compression 
occurred — that is, the signs resulting from the extreme degree of increased 
intracranial pressure — accounts for the high mortality of operations per- 
formed at this late period, and justified the opinion of so many observers 
in the past that the expectant palliative treatment of "fractures of the 
skull" is equally successful as the operative treatment. Patients, however, 
should not be permitted to reach this dangerous condition of medullary 
compression, as its cause and forerunner, high intracranial pressure, can 
now always be revealed by the routine use of the ophthalmoscope and 
accurately measured by the spinal mercurial manometer. Besides, an early 
decompression and drainage will not only save the lives of a large percentage 
of patients who otherwise would have died from medullary compression, but 
it will lessen the percentage of post-traumatic conditions so frequently 
following brain injuries with and without a fracture of the skull : in the mild 
cases, those vague indefinite headaches, associated at times with dizziness, 
a throbbing sensation in the head, and the early signs of fatigue, so com- 
monly observed and considered as ' ' post-traumatic neuroses " ; in the more 
severe cases, a complete change of personality — the patient becoming either 
very irritable and restless, indulging in fits of anger at the least provoca- 
tion, and having so little self-control that he is unable to hold any position 
permanently; or the reverse, very much depressed, with loss of ambition, 
a "happy-go-lucky," and in many patients, as the relatives have expressed 
it, a "bum" and "good-for-nothing"; epilepsy, especially in the minor 
form of "petit mal," and at times "grand mal" — is fairly common after 
depressed fractures of the vault, but fortunately it is more rare following 
basal fractures, due, possibly, to the resulting hemorrhage being more at 
the base and not over the cerebral cortex. 

Such has been the record of my following the histories of patients 
who have had brain injuries and the so-called "fractures of the skull," 
particularly of the base, and have been treated by the expectant palliative 
treatment in three of the large hospitals in New York City during the decade 
of 1900-1910. These patients remained in the hospital for periods of two 
to six weeks, and were almost without exception discharged as "well" or 
"cured." Naturally, it has been a most difficult undertaking to locate 
these patients, especially after a lapse of five years and more, and particu- 
larly since the vast majority of them were the usual ambulance patients 
of the poorer classes who change their residences almost as frequently as 
the seasons come and go ; my inability to locate more than 34 per cent, of 
them may thus be explained. The most striking thing, however, is that, of 
the patients found, 67 per cent, are still suffering from the effects of the 



WITH AND WITHOUT A FRACTURE OF THE SKULL 73 

brain injury and the "fracture of the skull" ; that is, they have not had the 
same good health since the accident as before — the most frequent complaints 
being headaches of greater or less severity, changes of personality of the 
exalted and of the depressed types, a nervous instability, and occasionally 
epilepsy in its various forms; that is, about two-thirds of the patients 
whom I was able to locate were not well. It is for this reason, no doubt, 
that it is popularly believed that ' ' once a person has had a fracture of the 
skull, he is never the same person again"; these statistics would tend to 
confirm this belief. 

The patients operated upon in these three hospitals were chiefly ones 
having depressed fractures of the vault ; upon those operated patients hav- 
ing ' ' fractures of the base of the skull, ' ' the operation was performed only 
upon the ones showing signs of definitely localized cortical compression 
and of marked medullary compression and even edema itself, and naturally 
the mortality was very high — being 87 per cent. Besides, an extensive 
bone-flap operation was frequently performed and the bone-flap then 
replaced, thus lessening and even preventing the benefits of a decompres- 
sion ; in some patients, the dura was not opened, and, therefore, the benefits 
of even a limited decompression could not be obtained, because the dura 
is inelastic in adults, and it always must be opened if a decompression 
is desired ; simply removing an area of bone is not a decompression. 

Of those patients having "fractures of the base" who were operated 
upon at the Johns Hopkins Hospital since 1900, 58 per cent, were located 
in 1913, and of this number 32 per cent, were suffering from the effects of the 
cranial injury ; of the patients operated upon since 1906, only 22 per cent, 
were still impaired, due undoubtedly to an earlier operative interference. 

My experience in hospitals of Boston and New York City, where the 
expectant palliative treatment was adhered to in "fractures of the base," 
and then later at the Johns Hopkins Hospital, where selected patients having 
a high intracranial pressure were operated upon comparatively early, 
strongly impressed me with the superiority of the latter treatment. During 
the past six years, I have advised the cranial operation of subtemporal 
decompression and drainage upon patients having brain injuries with and 
without a fracture of the skull as soon as definite signs of a marked increase 
of the intracranial pressure can be demonstrated by the ophthalmoscope 
and confirmed by the spinal mercurial manometer, and the results have 
been most gratifying ; not only is the danger of a medullary edema lessened 
by an early operation and an immediate relief of the intracranial pressure 
obtained and thus a higher percentage of recovery of life, but the number 
of the post-traumatic conditions, both physical and mental, has been very 
much diminished — to less than 14 per cent. 

In this series of 155 operated patients (to January 1, 1919), the per- 
centage of these patients still suffering from the effects of the brain injury 
with and without a fracture of the skull is 13.4 per cent. ; these were the 
extreme cases having cortical lacerations and numerous small hemorrhages 
in the cortex, as revealed at the operation. Naturally, sufficient time has 
not yet elapsed to render these figures regarding the post-traumatic con- 
ditions of the greatest value, and it will be necessary to wait at least five 



74 JJiALrlNUblb AINU 1 KiiA 1 'JVLEJN 1 UF J3KA1JN 1JNJUK1FS 

years longer in order to obtain more accurate data regarding them. For 
fear of being misunderstood, however, I wish to repeat that the cranial 
operation of subtemporal decompression and drainage is only for selected 
patients having brain injuries with and without a fracture of the skull — 
only in the ones showing marked signs of an increased intracranial pressure 
and comprising about one-third of the patients; whereas the expectant 
palliative method of treatment alone is sufficient for almost two-thirds of 
the patients — the ones having no marked signs of an increased intracranial 
pressure. Fortunately, it is a fairly frequent occurrence to have a fracture 
of the skull (confirmed clinically and by the X-ray) with no marked signs 
of intracranial pressure ; in these patients a cranial decompression can do 
no good and would be only an added risk. But, in patients showing marked 
signs of increased intracranial pressure, the early relief of this pressure is 
essential, not only to lessen the percentage of the post-traumatic conditions, 
but to avoid a medullary edema and its resulting high mortality. 

A. Expectant Palliative Treatment. — Shock. The presence of shock 
in varying degree is a factor in over four-fifths of the patients having acute 
brain injuries, so that its appropriate treatment is of the most urgent con- 
sideration ; the extreme shock must first be overcome and disappear early 
if the patient is to survive ; and unless this initial period of severe shock sub- 
sides, then the local cranial and intracranial examination and treatment must 
be deferred in the hope that the patient will react to the vigorous measures 
used to combat the shock. Almost 10 per cent, of the patients having 
severe brain injuries are unable to recover from this initial condition of 
extreme shock — frequently due to the absence and inefficiency of the proper 
shock measures being instituted as soon as possible following the cranial 
injury: the patient is permitted to lie upon the cold ground, pavement 
or floor until the ambulance arrives — a period of time varying from thirty 
minutes to one hour and even longer; a blanket may be thrown over the 
patient but rarely is he wrapped in blankets. (I am describing the usual 
" first aid" treatment afforded these patients by the policemen and onlookers 
following a typical accident in the streets of the city whereby the patient 
has been struck by an automobile, street car or subway train, or has been 
injured in an industrial accident.) An ambulance is summoned by the 
policeman, and everyone waits until the ambulance arrives — the patient 
receiving scant attention other than the "keeping-back" of the crowd, 
- ' give the man plenty of air, ' ' and so frequently the attempt to administer 
whiskey by mouth to an unconscious, or at most, a semi-conscious man. If, 
while awaiting the ambulance, the patient could be lifted from the ground 
or the floor to a bench, a counter or even a couch and bed, warmly wrapped 
in overcoats and even heated blankets, with several "hot" water bottles 
applied to the extremities and body, and no attempts made to waken and 
arouse the patient but rather "let him alone," it is my opinion that a larger 
number of these patients would survive this initial period of severe shock. 
Lying upon the ground and floor and inadequately wrapped, these patients 
are ' ' chilled through ' ' in addition to the shock of the cranial injury itself, 
and thus they undergo an exposure which ordinarily would produce a 
"cold" even in the presence of good health. The immediate "putting-to- 



WITH AND WITHOUT A FRACTURE OF THE SKULL 75 

bed" of these patients in heated blankets is rarely possible on account of 
the location of the accident. 

Upon the arrival of the ambulance, however, the patient should then at 
least be warmly wrapped in heated blankets (and it is rare for a hospital 
ambulance to have them, or even "hot" water bags or electrically heated 
stoves as now in very common use in a limousine in winter) ; the use 
of drugs hypodermically is rarely of great value in this stage of severe 
shock, although camphor in oil, caffeine, atropine and strychnia may be 
administered; codeine or morphia are excellent if the patient is conscious 
or restless. It is, however, the early routine use of vigorous external heat — 
best by means of heated blankets — and then keeping the patient as quiet and 
free from disturbing examinations, that these unconscious and semi-con- 
scious patients are most benefited and assisted in combating the condition 
of shock. Care should be taken by the driver of the ambulance not to 
"bounce" and jar the patient during a "fast" ride to the hospital; it has 
happened several times in my experience for the ambulance itself, under 
these conditions, to have accidents on the way to the hospital so that the 
original patient with the brain injury was joined by another patient simi- 
larly injured by the ambulance itself, and in one instance, by two patients. 
These "fast" and reckless ambulance trips through the city streets rarely 
if ever aid the patient being transported; a delay of iive or ten minutes, 
but in safety, is in no way harmful to a patient in an ambulance and attended 
by a competent doctor. 

Upon arriving in the ambulance at the hospital and in the condition of 
severe shock, if the patient can be placed immediately in a bed between 
heated blankets and with several "hot" water bags to the extremities and 
body and then not disturbed by examinations but permitted to remain in 
absolute quiet — that patient is indeed a most fortunate one. These patients 
in severe shock and having a pulse-rate over 110 should be treated for the 
shock alone : first and most important, external warmth, absolute quiet — 
morphia being administered freely in order to obtain it — and rectal ene- 
mata of hot black coffee in amounts of two to four ounces every two to four 
hours; camphor in oil hypodermically is excellent. Merely a superficial 
examination upon admission is sufficient in order to ascertain the presence 
or not of fractures of the extremities, internal injuries of the abdomen 
and chest, and to arrest any profuse hemorrhage ; scalp wounds should be 
widely shaved, thoroughly cleansed and loosely sutured, but to examine 
carefully and repeatedly the reflexes, to make ophthalmoscopic examinations 
and even a lumbar puncture in this stage of shock is meddlesome and of 110 
value, to the patient — in fact, a probable harm to the patient in prolonging 
and even increasing the severity of the shock. It does not benefit either 
the patient, in this stage of shock, or the doctor to ascertain the presence or 
not of a fracture of the skull, any inequality of the reflexes or the presence 
of blood in the cerebrospinal fluid — these data can be elicited after the 
shock has lessened or even entirely disappeared and then the appropriate 
treatment vigorously instituted, without any danger of producing shock. 
and in this manner the patient is afforded the best chance of immediate 
and ultimate recoverv. 



76 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

The history of these patients in most hospitals unfortunately is the fol- 
lowing : The patient is carried upon a stretcher from the ambulance into 
the accident-room of the hospital and placed upon an examining table — 
covered with padded leather frequently, but only too often not covered 
and not soft ; a blanket may or may not be placed over the patient and it is 
rarely, if ever, a heated and warm one. The interne of the hospital staff 
assigned to duty in the accident-room is now summoned; upon arriving, 
he obtains the history of the patient from the ambulance doctor and exam- 
ines the patient to determine whether the patient is severely enough injured 
to warrant the summoning of the resident house-surgeon to decide whether 
the patient should be admitted to the hospital ward or not ; upon his arrival, 
which may be delayed a number of minutes, and then after his examination, 
the patient is transferred to the ward or a private room and placed in bed — 
and naturally the bed should be warmed with "hot" water bags and the 
patient wrapped in two or more heated blankets. It will be seen, however, 
that the usual hospital patient has not only been not warmed and vigorously 
treated for this condition of shock, but that he has been repeatedly exam- 
ined — at the time of the injury, by the ambulance doctor, the accident-room 
doctor, the resident surgeon and finally sometimes even by the attending 
surgeon to the hospital ; a period of time varying from over one hour to even 
three hours may be consumed before the patient reaches a bed and is really 
warmed in the treatment of the shock. It is this delay in the appropriate 
treatment of many of these severely shocked patients that the condition 
of shock is prolonged, and only too frequently increased, so that the patient 
is unable to survive this extreme degree of shock ; these patients at autopsy 
may or may not reveal a fracture of the skull, and may, but usually they do 
not, disclose a large intracranial hemorrhage or an increased intracranial 
pressure due to cerebral edema ; the usual post-mortem findings are merely 
an anemic, pale condition of the brain and, even in the presence of rather 
large cortical vessels being torn, yet the amount of free hemorrhage is small, 
showing that the lowered blood-pressure of shock had not been of sufficient 
force to overcome the normal intracranial pressure and thus cause an intra- 
cranial hemorrhage ; if the shock had lessened, then the general blood- 
pressure would have increased so that it would have been possible in these 
patients for a large intracranial hemorrhage to occur and later its resulting 
high intracranial pressure. 

It is not a question in these patients in severe shock with a pulse-rate 
over 110 whether the skull is fractured or not or how badly, or whether there 
might be an intracranial hemorrhage or not, or whether it appears the 
patient is going to die : all efforts should be directed toward the lessening 
of the extreme condition of shock by raising the general lowered blood- 
pressure of shock — best accomplished by external warmth, absolute quiet, 
repeated rectal enemata of hot black coffee and the use of camphor in oil, 
caffeine, atropine or strychnia ; camphor in oil, hypodermically, has been, in 
our experience, possibly of greater value than any other drug for the condi- 
tion of shock, although hot black coffee by rectum is almost of equal value. 

The value of morphia for restlessness and also for the shock in many of 
these patients cannot be overestimated. Formerly, in conditions of brain 



WITH AND WITHOUT A FRACTURE OF THE SKULL 77 

injuries, the use of morphia was condemned for fear the drug would mask 
the symptoms and signs of an increasing, intracranial hemorrhage and 
therefore, the appropriate operative treatment be delayed and even 
omitted until the terminal stage of the condition. This criticism of the use 
of morphia was perfectly well justified several years ago, when the symp- 
toms and signs of an intracranial lesion indicative of the necessity of 
operative interference depended almost entirely upon the presence or not 
of paralyses, inequality of the pupils, a low and irregular pulse- and respi- 
ration-rate and an increased blood-pressure ; these signs, however, are now 
known to be most crude ones of the terminal stages of high intracranial 
pressure producing a medullary compression, whereas the use of the ophthal- 
moscope, and especially the spinal mercurial manometer, has made it possible 
to ascertain accurately the intracranial status of the intracranial pressure — 
whether due to hemorrhage or edema — and thus the use of morphia can in 
no way lessen or impair the value of the examinations. Morphia will produce 
a pupillary constriction but rarely a narrowing so small that a careful 
ophthalmoscopic examination cannot be made, and if it should, then the most 
accurate measurement of the pressure of the cerebrospinal fluid at lumbar 
puncture by means of the spinal mercurial manometer will still be possible. 

If the severity of the extreme condition of shock lessens so that the pulse- 
rate gradually descends from 130 or more down to 100 and lower, and the 
blood-pressure ascends from 100 or low T er up to 120 and higher, then a thor- 
ough neurologic examination becomes possible and yet the patient is in no 
way harmed by increasing or prolonging this mild condition of shock. 

As a routine method of treatment, the following measures are now 
important : 

I. Absolute Best in Bed, Quiet and Warmth. The room should be cool and 
darkened, and there should be the greatest possible freedom from noise and 
from disturbing elements. Relatives should be excluded from the sick-room 
unless the patient is unconscious, and even then it is a wise measure, and most 
assuredly if the patient is conscious, in order that the emotions be not 
aroused. Small repeated hypodermic injections of morphia (gr. %) are most 
useful for insuring quietness to restless, excitable and even delirious patients. 
The head should not be elevated beyond the height of one pillow, and 
frequently it is advisable not to raise the head at all, and even to lower it 
in the conditions of extreme shock by elevating the foot of the bed ; warm 
blankets and "not too warm" hot-water bags should be applied to the body. 
and even flannel or rubber bandages may be wrapped about the legs and 
also the arms. In conditions complicated by alcoholism, an immediate gastric 
lavage is beneficial. The patient should remain quietly in bed for at least 
a period of ten days to two weeks. All reading should be prohibited ; many 
"nervous breakdowns" following brain injuries result from the neglect 
of this simple precaution. The patient should not attempt to return to active 
business for at least a period of three months, and better, six months. 

II. Catharsis. Upon the subsidence of the severe shock, an enema of 
soapsuds or oil should be given, and if the patient is conscious, then a 
cathartic administered by mouth — either a saline or calomel in j ._> gr. doses, 
to be followed by a saline purge. Vigorous catharsis is very important, and 



78 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

yet in conditions of severe shock it should be delayed until the patient is 
recovering from the shock; naturally, if the patient is unconscious, then 
enemata only should be used. In the hospital, it is a routine procedure to 
give a soapsuds enema each morning for at least two weeks after the injury ; 
in these patients, the blood-pressure has been frequently observed to descend 
ten to fifteen points following a soapsuds enema with a large movement 
of the bowels. 

III. Cold Compresses to the Bead. After the severe condition of shock 
has disappeared, a large ice-bag (ice-helmet) surrounding the entire head 
should be applied. The coldness of the ice tends in a small way to lessen 
the cerebral circulation and thus diminish and even prevent intracranial 
hemorrhage and the cerebral edema resulting so frequently from injuries 
to the head; in this manner, a lowered intracranial pressure is obtained. 
The ice-bag should not be allowed to remain about the head for periods 
longer than one hour ; after an interval of one-half hour, it can be replaced 
for another period of one hour, and so on. Patients will frequently ask for 
the ice-bag to be replaced — it so relieves the "throbbing" in the head and 
the headache, and the request should always be granted, as the patient is an 
excellent judge of its efficacy ; the patient will not ask for the reapplication 
of the ice-bag if there is neither throbbing nor headache to be lessened. 

IV. Diet. For unconscious patients nothing by mouth, naturally, should 
be given; after two days, these patients will usually regain consciousness 
sufficiently in order to swallow ; if not, then nutrient enemata may be em- 
ployed. A liquid diet should be adhered to for several days ; any liquid food 
may be given, although milk and its modifications should be avoided for 
at least three daj^s after the injury, for fear of the formation of gas and the 
resulting abdominal discomfort. Alcohol in any form whatsoever should 
be avoided; however, if the patient is alcoholic, it is wise to administer 
at least one-half ounce of whiskey or brandy three times a day for fear of 
the possible onset of delirium tremens. After the patient's discharge from 
the hospital, red meats and meat soups should be banned for a period of 
three and, better, six months or a year ; the danger of increasing the irrita- 
bility of the cerebral cortex must always be remembered ; especially is the use 
of alcohol in any form whatsoever to be prohibited, and for years. 

V. Drugs. Except for the use of morphia in conditions of extreme rest- 
lessness and shock, and camphor in oil and hot black coffee per rectum as a 
routine procedure, there are few drugs worth mentioning in the treatment 
of brain injuries with and without a fracture of the skull. Strychnia may 
be given in conditions of shock, but its real value is doubtful. Most im- 
portant, however, in conditions of shock of varying degree is hot black 
coffee given slowly by rectum in amounts of four to eight ounces ; I have 
frequently seen remarkable improvement in the general condition of these 
patients after its administration and also following cranial operations of 
any great severity, when its value is of the greatest importance. Atropine 
in repeated doses of gr. x / 90 is of the greatest value in conditions of early 
pulmonary edema — a much-dreaded complication in the more seriously 
injured patients during either the period of initial shock or the terminal 
one of medullary edema. The routine treatment, as briefly outlined above, 



■ 



WITH AND WITHOUT A FRACTURE OF THE SKULL 79 

should be followed in all patients having a severe cranial injury — that is, 
an effort should be directed toward the prevention and lessening of an 
increased blood-pressure, and in this manner it is possible to lower, and 
even avoid, the formation of an increased intracranial pressure. Naturally, 
if the symptoms and signs of initial shock are the more prominent, then 
the treatment should be directed toward the relief of the condition of severe 
shock, and when this has been accomplished, then the intracranial condi- 
tion can be considered. 

If in a condition of extreme shock, then the patient should not be dis- 
turbed — not even for the purpose of making an examination. It will not 
benefit him, and in some severe conditions it may do him harm; the treat- 
ment remains the same as outlined above wmether the patient has a fracture 
of the skull or not, and for this reason a thorough physical and neurologic 
examination should be deferred until a definite improvement in the general 
condition of the patient and especially in the severity of the shock has 
been obtained. 

VI. Aseptic Measures. It is of the greatest importance in all lacerations 
of the scalp, and even in severe contusions, to shave carefully the surround- 
ing area — at least one inch beyond the margin of the laceration ; to remove 
all foreign bodies with scrupulous care, cleanse the wound thoroughly with 
green soap, and then carefully apply alcohol or a weak solution of iodine 
to the damaged tissues. If the underlying vault is fractured and there is 
a possibility of the adjacent dura being torn, then the greatest care must be 
used to avoid any cerebral irritation resulting from the use of the alcohol 
or iodine ; the immediate danger of thus causing epileptiform seizures would 
be a most serious complication as w r ell as an unnecessary and avoidable one. 
Gentle probing may be used to ascertain the true condition of the under- 
lying bone. The scalp laceration can now be sutured loosely with any of 
the usual suture materials and a drain of rubber tissue inserted at each 
end of the wound. The danger of infection from foreign bodies, hair, dirt, 
etc., and a resulting meningitis, is so great that the utmost care and strictest 
asepsis are essential in all wounds of the scalp ; only too frequently are such 
w T ounds carelessly treated — most commonly the surrounding scalp not being* 
shaved — and the results are at times appalling. 

If an extensive hematoma is present and of sufficient size that the over- 
lying scalp is very tense and therefore less viable and less resistant to a 
scalp infection, it is very important to ascertain the presence or not of 
a fracture of the underlying vault of the skull by an early rontgenogram. 
If there is a line of fracture of the underlying bone, then I feel it is better 
surgical judgment to aspirate the blood of the hematoma through a "clean'* 
area of the overlying scalp painted with iodine, and a firm compress and 
bandage applied. The great danger of these hematomata becoming infected 
and the easy and rapid transmission of the infection through the line of 
fracture intracranially, and thus a purulent meningitis and meningo- 
encephalitis, is a most serious complication ; it has occurred in several 
patients of this series of brain injuries. If there is no fracture of the bone 
beneath the hematoma and the overlying scalp is in an excellent condition 
and is not badly contused, then the gradual absorption of the blood of the 



So DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

hematoma will usually occur without any complication; however, in very 
tense hematomata, anc 1 especially if the overlying scalp is bruised and even 
infected, then it is most important for the hematoma to be aspirated, as 
it is possible for the superficial scalp infection to extend intracranially from 
an infected hematoma through the diploetic veins ; particularly is this true 
in the median areas of the scalp overlying the longitudinal sinus and its 
numerous tributaries. Besides lessening the danger of infection, the aspira- 
tion of the blood of the hematoma overlying a linear fracture of the vault 
facilitates the drainage of a possible extradural and of a subdural hemor- 
rhage and edema (if the dura itself has been torn), so that by this means 
alone the intracranial pressure is lessened and even prevented from reaching 
a height necessitating the operation of cranial decompression and drainage ; 
that is, the patient has decompressed himself through the line of fracture of 
the vault in a similar manner as through a basal fracture into the nose or 
ears — and with comparative safety and freedom of danger. Naturally, 
small hematomata do not render the overlying scalp so tense that the com- 
plication of infection is a probable one, and therefore they are rarely 
aspirated or drained unless the contiguous scalp is badly damaged and 
infected. It cannot be urged too strongly that the scalp of each one of these 
patients should be carefully shaved, scrupulously cleansed with green soap 
and water, and if necessary with alcohol, and sterile dressings applied; 
numerous complications will thus be avoided. 

VII. Lumbar Puncture Drainage as a Therapeutic Measure. After the 
shock of the cranial injury has been lessened so that the pulse-rate is 100 
and lower and the blood-pressure 120 and higher, it is advisable, in addition 
to the ophthalmoscopic findings, to ascertain accurately the measurement of 
the pressure of the cerebrospinal fluid at lumbar puncture by means of the 
spinal mercurial manometer ; not only will the presence or absence of blood 
be demonstrated, but, of the greatest importance, the intracranial status of 
increased pressure or not be established and thus the advisability of con- 
tinuing the expectant palliative method of treatment or, in the presence 
of a high intracranial pressure, the necessity of an immediate cranial opera- 
tion of decompression and drainage. It is very infrequent in these early 
cases for the condition of high intracranial pressure to be demonstrated 
either by the ophthalmoscope or by the spinal mercurial manometer on 
account of the recent condition of severe shock, and yet if an acute cerebral 
edema occurs — and it frequently does, especially in patients having cardio- 
vascular and cardio-renal disease and in those addicted to the daily use of 
alcohol — or if a large intracranial vessel has been torn, then as the shock 
subsides, the hemorrhage may be such a rapid and extensive one that the 
typical signs of low pulse- and respiration-rates and a high blood-pressure 
are frequently not possible and the condition of the patient may merge into 
that of medullary edema and collapse without the usual clinical signs of high 
intracranial pressure being disclosed. In these latter patients having an 
increased intracranial pressure to the height of over 16 mm. as registered 
by the spinal mercurial manometer, the immediate relief of this pressure, 
whether due to hemorrhage or edema, by means of a decompression and 
drainage is of less risk to the patient and offers a greater chance both 



WITH AND WITHOUT A FRACTURE OF THE SKULL 81 

of recovery of life and of ultimate normality, than the expectant palliative 
method of treatment. 

In the majority of patients, however — and they form almost two-thirds 
of the total number — the intracranial pressure was not increased or only 
mildly so — not over 12-14 mm. as registered by the spinal mercurial mano- 
meter, and therefore the expectant palliative treatment was alone sufficient 
to obtain an excellent recovery. It was frequently observed in many of 
these patients who had an increased pressure of possibly 12-14 and even 
as high as 16 mm., that after the lumbar puncture was performed and pos- 
sibly 10 c.c. carefully withdrawn for examination, a large percentage of 
them almost immediately improved in their general condition : their stupor 
lessened so that they became conscious, while the conscious patients who had 
been complaining of intense headache, restlessness and even nausea and 
vomiting, immediately "felt better" — the headache lessened and in a few 
patients it disappeared entirety, they became quiet and their nausea ceased. 
This improvement was only a temporary one in most of these patients, in 
that the complaints returned within several hours, and we were then im- 
pressed as to the advisability of performing repeated lumbar punctures upon 
these selected patients having only a mild increase of the intracranial 
pressure, not only by this temporary improvement but by the patients 
themselves, who in many instances asked that the "back be tapped again" 
and "the fluid removed." 

During the past three years, these selected patients having an increased 
intracranial pressure but of not sufficient height to make necessary the 
cranial operation of decompression and drainage, have been repeatedly 
treated by this method of drainage at lumbar puncture — in many patients 
the procedure has been used even five and six times, and the results have 
been very gratifying; not only is the general condition of these patients 
improved, but their convalescence is hastened. It should be remembered, 
however, that it is only in the patients having a mild increase of the intra- 
cranial pressure that this method of lumbar puncture drainage should be 
advocated and in whom the complaints of headache, restlessness and nausea 
are severe ; patients having a high increase of intracranial pressure — over 
16 mm. — should not be subjected to the risk of withdrawal of cerebrospinal 
fluid in amounts of 10-20 c.c. for fear that this high intracranial pressure 
would force the medulla into the foramen magnum owing to the sudden les- 
sening of the spinal pressure following the lumbar puncture, and thus the 
signs of a direct medullary compression would occur, and usually the early 
death of the patient. At the first lumbar puncture, if the pressure is high, 
then no fluid may be withdrawn, or at least not more than 5 c.c. should be 
slowly removed — merely for examination ; if the pressure is not over 16 mm., 
then 10 c.c. can be safely removed, and if the complaints of headache, etc., 
return after several hours, a second lumbar puncture may be performed ; 
if the pressure is again not over 16 mm., it is now possible to remove slowly 
and safely 15-20 c.c. of the fluid, and this procedure can be repeated safely 
as long as the pressure does not exceed 16 mm. In this manner, many 
of these patients who otherwise would recover slowly under the expectant 
palliative treatment alone and within a period of several weeks, but com- 
6 



82 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

plaining of the severe headache, etc., will make an excellent recovery within 
a period of usually ten days to two weeks. Besides, in a few patients this 
early removal and drainage of the excess cerebrospinal fluid, with and 
without the presence of blood, will so lessen and prevent the formation of 
a high intracranial pressure that it will not be necessary to perform the 
operation of cranial decompression and drainage ; that is, lumbar puncture 
drainage in these selected patients is really a spinal decompression and 
drainage. The improvement following each lumbar puncture drainage has 
usually been only a temporary one, and yet in the larger percentage of these 
patients the pressure registered at each succssive puncture has frequently 
not been so high as at the preceding one, and after two, three or more 
punctures the pressure does not exceed a height of 10-11 or at most 12 mm. 
— and the patient no longer suffers intense headache, and his general con- 
dition is improved in every way. This method of lumbar puncture drainage 
is of special value to patients whose condition is complicated by chronic 
alcoholism, or by chronic nephritis and arteriosclerosis; the great danger 
of a "wet" edematous brain resulting in these patients is a most serious 
one and the early repeated removals of 15-20 c.c. of cerebrospinal fluid 
may tend to offset this most serious complication; acute delirium tremens 
may also thus be avoided. 

B. The Operative Treatment. — The operative treatment of patients 
having brain injuries with and without a fracture of the skull is restricted 
to those patients only for whom the expectant palliative method is not 
sufficient either to obtain a recovery of life or to secure the greatest ultimate 
improvement, so that the later condition of the patient will approximate 
that of his former good health of the period before the injury. As has been 
stated, the expectant palliative method of treatment is entirely satisfactory 
and sufficient for almost two-thirds of these patients (if depressed fractures 
of the vault are excluded and for whom the operation of removal or eleva- 
tion of the depressed bone is always advisable ) , whereas the cranial operation 
of decompression and drainage is essential in about one-third of the patients 
in order that not only a greater percentage of recovery of life be obtained, 
but that the former good health of the patient be restored to its maximum. 
There is a small percentage of these patients, however, who have suffered 
a laceration of the cerebral cortex and naturally the cortical cells and 
subcortical fibres involved are not regenerated, and therefore a permanent 
impairment of them results ; fortunately, these cortical lacerations and severe 
cerebral contusions occur most frequently in the comparatively silent areas 
of the brain, such as the anterior portions of the temporo-sphenoidal lobes 
and of either frontal lobe, and especially their anterior superior surfaces, so 
that there is frequently little if any clinical evidence of the cerebral damage ; 
if, however, the laceration should occur in the motor cortex of either parietal 
lobe, or in the motor speech area of the left posterior third frontal convolu- 
tion (in right-handed patients) or in the definite sensory areas of the cortex, 
such as either parietal lobe posterior to the fissure of Rolando, the portion 
of either occipital lobe developed for the special sense of sight, or of either 
temporal lobe (and particularly of the left lobe in right-handed patients) 
specialized for hearing, taste, and smell, and if the laceration should extend 



WITH AND WITHOUT A FRACTURE OF THE SKULL 83 

subcortically into the fibres of the pyramidal tract above and below either 
internal capsule, then in these patients there persists a permanent impair- 
ment clinically of definite degree. The cortical cells and fibres adjacent to the 
laceration, however, may not be primarily destroyed but only functionally 
impaired by the compression of the associated hemorrhage and cerebral 
edema, so that as the hemorrhage and cerebral edema are absorbed by the 
natural means of absorption or the acute compression lessened in the patients 
having a high intracranial pressure by means of the cranial operation of 
decompression and drainage, then a marked improvement is frequently 
observed, although there always remains clinically the impairment of the 
cortical cells primarily destroyed by the laceration or the severe contusion. 

It must always be remembered that as long as the severe condition of 
shock persists so that the pulse-rate is higher than 110 and surely above 120, 
even though there are signs of high intracranial pressure (and this is a 
very rare observation in the condition of severe shock) , then the patient must 
first be allowed to recover from the extreme degree of shock before any 
operative procedure to lessen the increased intracranial pressure can be con- 
sidered. A cranial operation in this period of severe shock merely increases 
or at least prolongs this condition of extreme shock — the operation itself 
being an added shock — and the chances of the patient being able to survive 
the shock alone are thus diminished. It is possible for a large hemorrhage 
to have occurred intracranially immediately following the injury and before 
the condition of extreme shock has occurred, but as long as the condition of 
severe shock persists, then it need no longer be feared that the intracranial 
hemorrhage is becoming greater, because the general blood-pressure has 
been so lowered by the condition of shock — to 110 and even lower — that no 
more bleeding intracranially is possible until this extreme condition of shock 
has disappeared. If the patient survives this condition of shock, then the 
blood-pressure will ascend and it is now that the most careful and repeated 
examinations are essential in order to determine whether the intracranial 
pressure is increased or not, or whether it is of sufficient height — not above 
16 mm. as registered by the spinal mercurial manometer — in order that the 
expectant palliative treatment may be continued (and this method can be in 
about two-thirds of these patients), or whether the intracranial pressure is 
so high (above 16 mm.) that the operation of decompression and drainage 
is advisable in order to offer the patient a greater chance both of recovery 
of life and of future normality ; about one-third of the patients having brain 
injuries are more rationally treated by this operative method. 

It is, therefore, of the greatest importance after the extreme shock has 
subsided so that the pulse-rate has descended to 100 and even lower, and 
the blood-pressure has risen to 120 and higher, and the temperature to 
normal and above, that thorough neurologic examinations should be fre- 
quently made, ophthalmoscopic findings carefully recorded and the registra- 
tion of the pressure of the cerebrospinal fluid at lumbar puncture by means 
of the spinal mercurial manometer obtained at intervals according to any 
change in the other clinical signs. 

As long as the pulse- and respiration-rates do not descend to 60 
and to 16 and lower, respectively, and at the same time the ophthalmoscope 



84 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

does not reveal an edematous blurring of more than the nasal margins of 
the optic disks, or at most the nasal halves and temporal margins, and the 
spinal mercurial manometer registers the pressure of the cerebrospinal fluid 
as not being over 16 mm., and there are no localizing signs of convulsive 
seizures or paralyses of the extremities — then naturally no cranial operation 
should be considered advisable (unless there is a depressed fracture of the 
vault, which should always be elevated or removed) ; the expectant palliative 
treatment should be continued and if the signs of an increasing intracranial 
pressure do not appear, then the medical treatment alone is sufficient to 
obtain the best result possible ; the operation of cranial decompression and 
drainage upon this group of patients — forming about two-thirds of the 
patients injured — is not only not justified but is not indicated, since these 
patients can "take care of" this mild increase of intracranial pressure of free 
hemorrhage and cerebral edema by the natural means of absorption alone, 
and therefore these patients should not be subjected to the risk of a cranial 
operation. If, however, the signs of an increasing intracranial pressure 
appear in the gradual descent of the pulse- and respiration-rates to 60 
and to 16 and lower, respectively, the increase of the blood-pressure to 
110 and higher, and. most important, the definite signs of an edematous 
obscuration of the optic disks to the degree of an early papilledema or even 
a measurable swelling of two diopters and higher (although this latter 
finding of "choked disks" is uncommon), and the pressure of the cerebro- 
spinal fluid at lumbar puncture should now exceed 16 mm. and even 20 mm., 
and especially in the presence of an increasing paralysis of the extremities 
and epileptiform seizures of Jacksonian character or not, then there should 
be no hesitation whatever in advising an immediate operation of cranial 
decompression and drainage. To postpone the operation now until the more 
distinct signs of medullary compression occur, as would be indicated by the 
very slow and irregular Cheyne-Stokes type of pulse- and respiration-rates, 
with or without an increasing and profound unconsciousness, and a papill- 
edema to the degree of even ' ' choked disks, ' ' and a pressure of the cerebro- 
spinal fluid of 21 mm. and higher — this condition would be a most dangerous 
one for the patient to reach ; the early onset of the signs of medullary edema 
and collapse (a rapidly increasing pulse- and respiration-rate to 100 and 
30 and higher, respectively) might appear within several hours and even 
earlier, and thus the certain death of the patient. Besides, the value of 
the operation of cranial decompression and drainage for these patients after 
they have entered the clinical stage of acute medullary compression is a 
doubtful one in that the mortality is high even with the immediate operative 
relief of the high intracranial pressure — that is, the medullary compression 
merges into the condition of medullary collapse before the beneficial effects 
of the cranial decompression are possible because the resistance of the 
cardiac and respiratory centres in the medulla has been so diminished by 
the high unrelieved intracranial pressure that an edema of the medulla 
occurs, and once it occurs these patients all die — operation or no operation. 
Formerly, the only methods of estimating, in a crude way, the presence 
of a high intracranial pressure were the descent and ratio of the pulse- and 
respiration-rates, associated with the height of the general blood-pressure — a 



WITH AND WITHOUT A FRACTURE OF THE SKULL 85 

most unsatisfactory and late means of establishing definitely the necessity 
of a cranial operation ; naturally, the mortality was therefore high, not only 
from an inefficient technic but chiefly from the fact that the operation 
was performed at such a late stage of acute medullary compression that the 
condition of medullary edema was imminent and at times even hastened 
by the operation itself. 

The more accurate methods of ascertaining the intracranial pressure by 
means of the ophthalmoscope and the spinal mercurial manometer in addition 
to the pulse- and respiration-rates, blood-pressure and the presence or not 
of profound unconsciousness, paralyses and convulsions — this advance in 
the diagnostic methods has made it possible to anticipate these cruder clinical 
signs of an approaching medullary compression, so that the intracranial 
pressure can be relieved earlier, with greater safety and with a much lower 
mortality rate. It is not to be doubted that there are patients who have 
been in this stage of acute medullary compression with a pulse-rate of 50 
and even lower, and yet they have recovered life without a cranial opera- 
tion; their constitutional resistance to this high intracranial pressure has 
enabled them to withstand it successfully, and yet these patients (and 
I have followed a number of them) rarely if ever regain their former good 
health but are permanently damaged to a greater or less degree from having 
endured this high pressure over a period of days, and usually longer. It 
is, therefore, not only the immediate recovery of life of the patient which 
must be considered but also his future ultimate condition of normality, and 
there is no question that the early operation of cranial decompression and 
drainage affords these patients the best chance of complete recovery. 

It is now realized, therefore, that the two periods in which no cranial 
operation should be performed upon these patients is, first, during the initial 
period of severe shock with a pulse-rate above 110, and then, second, the 
terminal period of medullary edema and collapse when the pulse- and 
respiration-rates have reached their lowest levels of 50 and 12 and even lower, 
respectively, and have begun to rise rapidly to 100 and 30 and higher, 
respectively. If a patient survives an operation during this first period of 
severe shock, then he recovers in spite of the operation, whereas if a patient 
should survive a cranial operation after the clinical signs of an acute medul- 
lary edema have appeared — well, it does not happen, and I have yet to see 
a patient recover from this extreme terminal condition — operation or no 
operation. In conclusion, as stated before, only about one-third of the 
patients having brain injuries require a cranial operation, while the other 
two-thirds can and do make excellent recoveries under the expectant pallia- 
tive method of treatment. If the intracranial pressure, however, exceeds 
a height beyond which it is not considered probable that the expectant 
palliative method will be sufficient to obtain the best result as to life and 
future normality, then the ideal time for the cranial operation of decom- 
pression and drainage is before the period of acute medullary compression. 
and this can be ascertained by the more recent methods of examination — 
particularly the intelligent use of the ophthalmoscope and of the spinal 
mercurial manometer. If the patient is already in the stage of acute medul- 
lary compression, of lowered and irregular pulse- and respiration-rates, then 



86 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the cranial operation at least offers the patient a definite chance to recover 
life, bnt the relief of the pressure afforded at that late period may not be 
sufficient to obtain the best result ; it should, however, be attempted. 

Choice of Operation. — In depressed fractures of the vault of the skull, 
the depressed area of bone should naturally be elevated or removed; if, 
however, there is present a marked increase of the intracranial pressure — 
at least above 16 mm. — then a subtemporal decompression should first be 
performed on the same side of the head as the depressed area of bone, and 
then the latter can be safely elevated or removed — at the same operation or 
at a second operation several days later. It is distinctly dangerous to elevate 
or remove a depressed area of the vault if the underlying dura is torn and 
the intracranial pressure is high, for fear that the adjacent cerebral cortex 
will be forced upward through the bony opening and thus be irreparably 
damaged. This unfortunate complication frequently occurs in these patients 
having a high intracranial pressure unless the precaution is first taken of 
relieving the pressure by means of a subtemporal decompression. 

The osteoplastic ' ' flap ' ' operation is rarely of application and of value in 
these patients having brain injuries. Not only is it a much more formidable 
operation than the subtemporal decompression in that it is a greater shock 
to the patient by requiring a longer time — at least one hour and more, and 
the loss of blood is greater, but the intracranial lesion in these patients is 
rarely of such a situation and character that it can be definitely stated that 
the intracranial hemorrhage is limited to one particular portion of the brain, 
and therefore indicating that a certain cortical area must be exposed. In 
almost all of these patients, there are no accurate localizing signs pointing 1 
to more than a lesion of either cerebral hemisphere, and this results from the 
fact that the usual lesion is a subdural free hemorrhage, and supracortical 
rather than localized in the cerebral cortex itself, and also to the great 
frequency of an acute cerebral edema alone — that is, a "wet" edematous 
condition of the brain resulting from an excess of the cerebrospinal fluid; 
these conditions naturally do not present any definite localizing signs clini- 
cally other than the involvement of one cerebral hemisphere more than the 
other. Besides, to perform an osteoplastic "flap" operation over the more 
developed areas of the cerebral cortex and particularly above and adjacent 
to either motor tract and in the presence of a high intracranial pressure — 
the risk of a permanent damage to these important areas would be very 
great indeed ; such impairment following these operations in the past almost 
discredited the operative treatment of selected cases of brain injuries — so 
much so that the patient was considered to have an equal chance of ultimate 
recovery without a cranial operation as with one — and possibly more so. 

The advantage of the subtemporal route over other methods of cranial 
decompression is chiefly due to its anatomical relations; not only is the 
squamous bone underlying the temporal muscle the thinnest part of the 
vault of the skull and therefore less difficult to remove, but it exposes a part 
of the cortex most frequently involved in cases of brain injury with and 
without a fracture of the skull where the middle meningeal artery is torn 
or the temporo-sphenoidal lobe is lacerated, and in cases of abscess of the 
temporo-sphenoidal lobe following its usual cause — an otitis media; with 



WITH AND WITHOUT A FRACTURE OF THE SKULL 87 

little difficulty, the lower portion of the motor tract may be explored as 
well as the posterior portion of the frontal lobe; and on the left side the 
motor speech area is easily observed. Another important advantage is the 
fact that the part of the brain lying directly beneath the decompression 
opening is the cortex of the temporo-sphenoidal lobe — a comparatively silent 
area of the brain; for this reason any possible operative damage is not 
revealed clinically, and in patients having a high intracranial pressure, 
the protrusion of this part of the brain into the decompression opening does 
not produce paralyses, etc., — a frightful result of "decompressions" at times 
performed over the parietal bones. That is, a subtemporal decompression 
relieves increased intracranial pressure without the danger of cerebral im- 
pairment; besides, it affords excellent drainage for the middle fossa of the 
skull at its lowest point — a very important consideration in patients having 
brain injuries. 

Again, the thick overlying temporal muscle not only makes possible a 
firm closure but also allows the underlying bone to be removed so that a 
permanent decompression results with no danger of a hernia cerebri. 
The scalp is not weakened by drainage through the lower angle of the split 
temporal muscle and no unsightly protrusion occurs; the scar is always 
inside the hair-line. Besides, in men, the rim of the derby or straw hat 
affords some protection to the area of decompression although no protection 
is really necessary, as the temporal muscle is thick and thus the underlying- 
cortex is more protected than the eyeball ; besides, the underlying cortex 
itself is comparatively a silent area of the brain so that even if it were 
injured by some sharp object being thrust into the opening, no clinical 
signs would appear unless an acute infection should result; this possible 
remote complication has not occurred in any of the operated patients. 

The vertical incision in this operation is far superior to the older method 
of a curvilinear incision over or at the parietal crest. Not only may the 
manual pressure-traction method of hemostasis be used much more effectively 
with the vertical incision, but the temporal artery is clamped at its lowest 
point at the very beginning of the operation and before the artery branches 
into numerous smaller vessels, whereas, in the curved incision, the many 
branches of the temporal artery are severed individually and each one must 
be clamped separately ; again, it is easier to enlarge the bony opening- 
downward to the base of the skull when the vertical incision is used — 
a very important point for drainage in cases of brain injury with and 
without a fracture of the skull. To preserve the strong attachment of the 
temporal muscle to the parietal crest is very difficult and even impossible 
when the usual curved incision is used; in this manner, the decompression 
may so weaken the side of the head that a hernia cerebri appears as the 
intracranial pressure increases ; especially is this true in irremovable tumors 
of the brain. This complication is a most rare occurrence following a 
decompression performed with the vertical incision and with a careful 
regard for the attachment of the temporal muscle. 



CHAPTER VIII 

The Technic of the Operation of Subtemporal Decompression 

The usual general preparation of the patient for an operation is the 
restriction of diet and the administration of a soapsuds enema several hours 
before the operation. The entire head or merely the side of the head selected 

PAR/ETAL CREST FOR 
ATTACHMENT Of TEMPORAL 
MUSCLE, 

--DOTTED L//VE OF BONY 
DECOMPRESS/ON 0PE///A/6. 




■^ ZYGOMA REMOVED S//OMALG 
-A~ ATTACHMENT OP TEMPORAL 
MUSCLE TO L//EERLOR MAX/LLA . 



Fig. 17. — The anatomical relations of the right temporal muscle with its attachment to the parietal 
crest above and to the inferior maxilla beneath the zygoma below; its diameter is usually three inches and 
more in adults, and forms an ideal protection for the underlying bony opening of the subtemporal decom- 
pression (indicated by the dotted line). The direction of the muscle fibres illustrates how easy it is to 
separate them longitudinally and vertically. 



PARIETAL CREST. 



SQUAMO' PARIETAL 
SUTURE. "- 

LINE OF VERTICAL 
SCALP INCISION:" 

LOBE OF EAR-- 



RI6HT MASTOID BONE: 



SQUAMOUS PORTION OF 
RIGHT TEMPORAL BONE 




LOWER PORTION OF 
RIGHT PARIETAL BONE . 



-RIGHT MIDDLE 
MENINGEAL ARTERY. 



DOTTED LINE INDICATING 

AREA OF UNDERLYING BONF 

REMOVED. 



ZrGOMATIC PROCESS. 



Fig. 18. — The extent of the vertical scalp incision in relation to the underlying squamous portion 
of the right temporal bone and the lower part of the right parietal bone; the right middle meningeal artery 
is seen curving upward and backward. The dotted line of removed bone reaches the base of the skull— 
the middle fossa. 

for operation is carefully shaved, either on the preceding night and a green 
soap poultice applied or in emergency patients the operative area is closely 
shaved just before the operation. Unless there are clinical signs indicating 
a lesion of the left cerebral hemisphere, the decompression to lower an in- 
creased intracranial pressure is always performed on the right side in order 
to avoid the motor speech area, which is situated in right-handed persons in 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 89 



the posterior portion of the third left frontal convolution, and vice versa in 
left-handed patients. The anatomical relations are illustrated in Figs. 17 
and 18. The patient is placed upon his back with the right shoulder slightly 
elevated by a sand-bag so that the right side of the head can be more easily 
made parallel to the horizontal plane of the table ; in this manner, the opera- 
tive site is well exposed and it does not compel the operator, whoi stands at 
the head of the table, and his assistants to assume tiring positions. The 
anesthetist is seated under a sterile sheet at the waist of the patient, and in 
this way he is entirely excluded from the field of operation. The anesthesia of 
these patients requires the most skilful administration ; especially is this true 
to avoid an extreme 
cyanosis and congestion 
during the induction of 
narcosis and also after 
the dura has been incised 
and the cerebral cortex 
exposed ; coughing or even 
labored respiration at this 
stage of the operation 
may result disastrously 
by forcing the cortex 
through the bony opening 
so that even the cortex 
may be ruptured and 
serious hemorrhage occur. 
Dr. Charles S. Hunt, who 
has administered the an- 
esthesia to most of my 
patients, uses a mixture of 
ether and oxygen very 
successfully (Fig. 19) ; he 
has found it necessary to 
deepen the narcosis just 
before the dura is incised, 
otherwise the sudden low- 
ering of the intracranial pressure will allow the patient to show signs of 
consciousness, coughing, etc., — a complication to be feared greatly at this 
stage of the operation. 

The side of the head and face are now carefully ' ' scrubbed ' ' with green 
soap and water for five minutes, and then alcohol (70 per cent.) is sponged 
over the operative area. Iodine is only used in emergency cases when the 
scalp cannot be thoroughly prepared; it tends to irritate the skin of many 
patients, especially children, and thus renders a secondary infection possi- 
ble. A superficial vertical incision of the skin (Fig. 20) is now made to 
indicate the extent of the scalp incision and then dry sterile towels arc 
clipped to the scalp at each side of this incision by towel clips (Figs, -1 
and 22) ; in this manner, the head is completely covered and the towels 
cannot become disarranged, so that there is little danger of infection. 




Fig. 19 



The superficial scalp incision in relation to the parietal 
crest (A); and to the zygoma (B), and the external auditory 
meatus (C). The ether-oxygen apparatus in position (D). 



go DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



By using the method of bimanual pressure-traction at each side of the 
incision and the forefinger of the assistant firmly applied so as to compress 
the temporal artery as it ascends above the zygoma (Fig. 23), the incision 
can be made with very little loss of blood — a most important factor in all 
cranial operations; a cranial tourniquet cannot be used in this operation 
and the other methods of controlling hemorrhage of the scalp such as sutur- 
ing the scalp, clipping of the scalp, etc., are not only time-consuming, 
troublesome, and even dangerous by increasing the risk of infection, but 
they are ineffective in many patients. 

The incision is made vertically upward through the scalp from a point 
just above the zygoma and one-half inch anterior to the external auditory 
meatus, to the middle of the parietal crest and thus overlying the origin 
of the temporal muscle; it is about three to three and one-half inches in 

Parte Pa I creat far attachment" > ; 
if temporal muscle 



. Vcrficle 
aKi'n incision 



External auditory 
meaToo 




's:\tqorr\a 



Fig. 20. — The vertical skin incision of about three inches extending from the zygoma upward to the 
attachment of the temporal muscle to the parietal crest and no higher — a very important factor in obtaining 
a firm closure of the temporal muscle and thus preventing any hernial protrusions. 

length, and is parallel to the fibres of the underlying temporal muscle. 
Small curved hemostats (Fig. 24) applied to the subcutaneous fascia are 
used to compress the branches of the temporal artery and then the temporal 
fascia is incised vertically (Fig. 25) and the fibres of the temporal muscle 
are split longitudinally and retracted, exposing the squamous portion of 
the temporal bone (Fig. 26) . A sharp periosteal elevator is used to separate 
the muscle from the underlying bone ; great care should be taken not to 
destroy the attachment of the muscle and its fascia to the parietal crest ; 
otherwise, the closure of the temporal muscle will be greatly weakened. 

The Doyen perforator and burr (Figs. 27 and 28) are now employed 
to make a small bony opening at the lower angle of the operative area, that is, 
the thinnest portion of the squamous bone (Figs. 29 and 30). Small 
rongeurs (Fig. 31) enlarge the opening (Fig. 32) until it is possible to use 
a larger rongeur having one blade levelled and flattened (Figs. 33 and 34), 
so that it can be easily and safely inserted between the dura and bone: 
frequent explorations and removal of adhesions between the dura and bone 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 91 



TOW£L FASTENED TO 
SCALP BY TOM/EL CLA/VP 




TOWEL CLAMP 



Fig. 21. — The method (actual size) of covering the skin (and thereby lessening the danger of 
infection) by clamping the towels to the skin itself; a wider exposure of skin is not only not neces- 
sary, but it is dangerous; the lobe of the ear cannot be made surgically clean. 



92 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




Fig. 22.— Top view (actual size) of a towel-clip which holds the towels firmly clipped to the scalp, 
thereby covering the skin and excluding it from the operative field and also preventing any slipping of the 
towels and consequently the great danger of infection. 




Fig. 23. — The use of bimanual pressure-traction at the side of the vertical incision of the scalp, and 
the compression of the temporal artery (A) by means of the forefinger of the assistant's right hand (B) ; with 
the left hand (C), the assistant compresses the vessels of the scalp on one side, while the left hand (Z>) of the 
operator is applied to the other side of the scalp incision. No other method of hemostasis, such as the use 
of a cranial tourniquet or a continuous scalp suture, is necessary. 




Fig. 24. — Lateral view (actual size) of the small curved hemostats used for clamping the subcutaneous 
fascia of the scalp and folding it backward, so as to compress the small vessels of the scalp and thereby 
avoid the necessity of clamping each vessel separately. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 93 



- - TOWEL PASTE /VED TO 
SCALP B/ TOWEL CLAMP 



TOWEL 



TEAfPOPAL FASC/A-- 
COVEP///G TEMPOPAL WSCLE 




DOTTED L/A/E /PD/CAT/A/G 
/MC/S/OP TPPO//GP TEMPOPAL 
FASC/A A/VD SEP/I/9AT/PG - " 
LOPG/T/JD/A/ALLy TPEF/BPES 
Of THE TEMPO/ML WSCLE 



TOWEL 




TOWEL CLAMP 



Fig. 25. — The skin incision down to the underlying temporal fascia ; by the method of bimanual pressuro- 
traction upon the edges of the scalp incision, the bleeding is practically nil: small curved hemostats arc now- 
attached to the subcutaneous fascia so that any possible bleeding points are thus compressed by the hemo- 
stats being turned down. 



94 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



TEMPORAL EASC/A-- 

10WEM POffr/ON- 

OF PARIETAL BONE 
TEMPORAL MUSCLE- 




SHIN 

SUBCUTARTOUS T/SSL/E 

TEMPORO-PAR/ETAL 
SUTURE 

DETRACTORS 
SEPARAT//VG TEMPORAL 
MUSCLE AW EASC/A 



SQUAMOUS PORT/OR— 
OE TEMPORAL BORE 
AMD MS TWA/REST 
AREA 

Fig. 26. — The retraction of the temporal muscle and fascia exposing the underlying lower portion of 
the parietal bone and the squamous portion of the temporal bone: an area of bone of three inches in 
diameter can thus be exposed and removed. 





rr 




I ■■ "T -r 



Fig. 27. — The Doyen in- 
strument with its perforator 
(A) and its burr (£). 



Fig. 28. — Diagrammatic cross-sec- 
tions of the vault showing the safe 
method of opening the skull: a pin- 
point opening is made by the Doyen 
perforator (A) and then enlarged by the 
Doyen burr (B), so that the small 
rongeurs can be inserted; in this manner, 
the dura and the underlying cerebral 
cortex are never injured, and the middle 
meningeal artery can be avoided; the 
use of even a small trephine is thus con- 
train cheated. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 95 

with the dural separator (Fig. 35) will prevent the dura from being torn. 
In this manner, a circular opening as large as possible under the temporal 
muscle is made, extending from the base of the skull up to the parietal 
crest and having a diameter of three to three and one-half inches. 

Before opening the 
dura, it is very impor- 
tant that all oozing from /^^\> fi<\ .. ■ 
the bony margins should 
be stopped; the best 
method for controlling j / ^ 
this bleeding from the 
diploe and its sinuses is \ /, 
the rubbing of bone-wax 
into the edges of the bone 

-. • , • • . , Fig. 29. — Using the Doyen perforator (4) to open the skull 

and It IS Surprising JlOW at the lower angle of the incision— the thinnest portion of the 

m-rifiVhr +Tiic tmnhlpcrvmo squamous bone. The Doyen burr (B) is next used to enlarge this 

quiutviy Liiia Liuuuiebum^ opening for the insertion of the small rongeurs. 

complication is over^ 

come. Dr. Norman Sharpe has formulated a bone-wax which is most 

effective; its composition is as follows: 

White Wax 7 parts 

Almond Oil 2 parts 

Salicylic Acid 1 part 

SKIN. 

TEMPORAL FASCIA.-^ ^ SUBCUTANEOUS TISSUE, 

PARIETAL BONE. 

TEMPORAL MUSCLE. <'*^Sb ' - TEMPOROPARIETAL SUTUXl 




THINNEST PART 

OF SQUAMOUS BONE . 




-MIDDLE MENINGEAL ARTERY 
SQUAMOUS PORTION OF TEMPORAL BONE. 



PIN-POINT OPENING OF BONE 
EXPOSING DURA 



PERFORATOR 



BURR 



Fig. 30. — At the lowest and therefore the thinnest part of tUe squamous Done, the Doyen perforator 
(A) is used to make a pin-point opening down to the dura, and then the Doyen burr (B) enlarges the open- 
ing down to the dura so that small rongeurs can be inserted to remove the bone; care is taken to avoid 
an injury to the adjacent middle meningeal artery. 

Keep in a 5 per cent, solution of carbolic acid. This wax may be sterilized 
before each operation, and then allowed to cool so that it hardens and is 
easily moulded; small pellets, the size of peas, are then rubbed into the 
oozing bone. It is a most effective method of plugging the middle meningeal 
artery when it channels the bone ; it seems to me that it might be used in 
operations upon bone elsewhere, such as extensive resections of bone. etc. ; 
it is far superior to the old method of using wooden pegs in cranial surgery. 



9 6 



DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



SQ(/AAfO(/S #OAf£ 
\ 

\ 
\ 

\ 

\ 





*£>(//? A. 



Fig. 31. — Small rongeurs enlarging the bony opening after the use of the Doyen hurr, 



TEMPORAL FASC//I 
TEMPORAL A/{/SCLEr 



BO/WOPEA/WG 

£WL/1/?GEJD ■ 
BY /?0/VG£(SE?S 

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OETEMPO/P/IL 
BO/VE. 

- £OMFX BPA/YCM Of 
M/0DLE A/£Af/#e£AL 

APTEPV. 



Fig. 32. — Bony opening being enlarged by rongeurs backward, downward and upward, but not for- 
ward until last on account of the middle meningeal artery lying adjacent to the anterior portion of the bony 
exposure; if the artery should be torn, the hemorrhage can be very easily controlled either with bone wax, 
a silver clip, or, if necessary, by a small packing of gauze tape. The final size of the bony opening is about 
3 inches in diameter. 




Fig. 



33. — Larger bone rongeurs, haying the thin lower blade bevelled for insertion between the dura and 
the overlying bone, which can now be safely removed at no risk to the dura itself. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 97 




M/DDLE MEN/NGEAL 
ARTERY. 



DURA. 



SE VEILED BLADE OF RONGEURS '. 



Fig. 34. — Bony opening being extended by larger rongeurs having one blade flattened and bevelled 
so that it can be easily inserted between the dura and the overlying bone without danger of tearing the 
dura itself. 




Fig. 35. — Lateral view (actual size) of the dural separator for insertion between the bone and the 
underlying dura and the removal of dural adhesions to the bone so that the danger of tearing the dura 
by the rongeurs is practically nil. 



attachment of the temporal 
muscle and fascia to the * 
parietal crest being kept 
intact; very impor ta nt. 



DURA 



SKIN. 

-SUBCUTANEOUS TISSUE. 



TEMPORAL MUSCLE, 
FASCIA . 




AND 



DOTTED LINE INDICATING 

'CRUCIAL INCISION 
c\ OF THE DURA 



BONY EDGE. 



MIDDLE MENINGEAL ARTERY. 



Fig. 36. — Opening of the dura: the underlying dura is now opened as widely as possible by erucial 
and then by stellate incisions; the dural hook and the grooved director are first used, then the spoon-spatula 
and dural scissors to enlarge the dural opening; the branches of the meningeal artery are ligated by the 
silver clips. 



9 8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




*"Sr"\ DURA. 

\ MIDDLE MEN' 

/NGEAL ARTERY. 

"DURAL HOOK INSERTED 
/NTO OUTER LAYER Of 
DURA. 



Fig. 37. — Small dural hook (.A) inserted into the outer layer of the dura and being used to elevate thi 
dura from the underlying cerebral cortex in order that a small dural incision may be safely made. 



DURA\* 



Fig. 38. 




-SKIN. 

SUBCUTANEOUS TISSUE. 
—TEMPORAL FASC/A AND 
MUSCLE. 
-GROOVED DIRECTOR. 

MIDDLE 
'MENINGEAL ARTERY. 



BONY EDGE OF 

DECOMPRESS/ON 

OPENING . 

DOTTED LINES (CRUCIAL) 
INDICATING DURAL INCISION. 



TEMPORAL MUSCLE 



-Grooved director carefully inserted into dural opening and supracortically in order that the 
dural opening may be enlarged in a crucial manner. 



In fractures of the skull, the middle meningeal artery is frequently torn as 
it channels the bone of the vault, so that it is a very simple matter to 
remove the extradural clot and then plug the bony channel of the bleeding 
vessel with the wax. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 99 



The dura is now incised in a crucial manner (Fig. 36) by carefully cut- 
ting through its outer layer first with a sharp knife, and then elevating the 
dura from the underlying cortex by means of the small dural hook inserted 
into its outer layer (Fig. 37) ; the inner layer can then be safely incised 
until a small pin-point opening is made. A grooved director bent almost at 
right angles may now be carefully inserted and the dural opening enlarged 
by cutting the dura upon the director (Figs. 38 and 39). When the dural 
incision is one inch in length, 
it is easier and faster to in- 
sert a spoon-shaped spatula 
(Fig. 40) beneath the dura 
and then to cut the dura with 
a sharp pair of scissors ; this 
method is not only safer, but 
it allows the dural incisions 
to approach the dural vessels 
as closely as possible so that 
these vessels may be clamped 
before being cut. Not only 
is it time-consuming and 
troublesome to ligate the 

t 1 -1 .,-, • ■,-. , Fig. 39. — Incising the dura upon the grooved director (A) 

dural VeSSelS With Silk Or Cat- downward to the lower branch of the middle meningeal 

„ 1lf i^^j. • + • Jo^^^nc, +„ artery (C), which is liga ted by two silver clips and then severed 

gill, UUl 11 IS uangeiOUS tO between them; the cerebral cortex {B ) is thus exposed. 

insert a needle beneath the 

vessels before the dura has been incised for fear of puncturing one of the 
many cortical vessels lying beneath, and thus complicating the operation 
very much indeed ; if the decompression is to be performed, it should at least 
not injure the brain. An excellent method of clamping the dural vessels is 
the application of small silver V-shaped clips to them and then the dura and 





Fig. 40. — The spoon-spatula — a very useful instrument for protecting the underlying cerebral cortex 
when cutting the dura with the small dural scissors; it is also of much value in facilitating the exploration 
of the adjacent cerebral cortex beneath the bony margins of the decompression opening. 

its vessels may be safely cut between each pair of clips and no bleeding re- 
sults (Figs. 41 and 42). These silver clips may be left upon the dural vessels. 
and I have never seen any ill effects occur ; in five cases at autopsy within two 
years after operation, the clips were found in situ and no tissue reaction had 
occurred, so that they are apparently not irritating foreign bodies ; in some 
patients when the dura was very vascular, as many as eight clips were ap- 
plied, although the usual number is not more than three or four. The clips 
are made by wrapping German silver wire, No. 24, snugly around a rectangu- 
lar rod and then bisecting the rolls (Fig. 43) ; Y-shaped clips are thus formed 



ioo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




Fig. 41. — The ligation of the middle meningeal artery (A) in the dura by means of a silver clip (B) being 
compressed by the clip-holding forceps (C) about the vessels; one clip (D) has already been applied. 



PAP/EE/1L LOBE 
CO/Vl/OLt/r/MS. 

S/LM&? Cl/PGMtfP/NG 

THEME/V/NGEJL 
ABTEPK 

UPPEP r£ffP0/?/h 

co/woii/r/o/v. 

3/LI/EP CL/P 
Af/DDLE TEMPOPAL 
CONVOLl/r/O/V. 




SVBCt/r/lA/EOt/S 

r/ss(/£- 

~-T£MPOA?Al. M(/5CIE- 
FASC/A. 
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A7E/V//VGEAL A/?T£Py< 
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Pt/BBEP T/SSl/E DPA//V 
/MSEPTE0 W/TP/W Dt/BA 
AMD BE /VE ATM TEMPO PAL I OSS 
/MTO WE Af/DDLE CRANML EOSSA • 

Fig. 42. — The dural flaps opened by stellate incisions and showing the underlying bulging cerebral 
cortex of the lower parietal lobe and the upper portion of the temporo-sphenoidal lobe; also the clamping 
of the dural vessels by means of silver clips. A rubber tissue drain is inserted at the lower angle of the 
incision and beneath the dura into the middle fossa of the base; hemorrhage and excess cerebrospinal fluid 
can thus be drained and a "water-logged" brain be decompressed. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 101 



C/?OSS 

SEcr/o/v — clis 











Fig. 43. — Method of making silver clips for the ligation of the dural vessels: silver wire (No. 24) is 
wrapped snugly around the rectangular grooved bar (A), and then cut in the groove on each side (B), by 
the wire-cutting scissors (C); the V-shaped silver clips CD) are placed in the grooves of the holder (E), 
inserted into the cover (F), sterilized and are then ready for use. The grooved forceps (G) for holding 
the silver clips facilitate their application to the dural vessels which are compressed by the closure of the 
forceps and the clips thus ligate the vessels by remaining in situ ; the vessels may thus be cut safely and 
rapidly and no bleeding occurs; no ligatures are therefore necessary. 




BOW EDGEr 



TEA/POPAL - 
ML/SCLE*"* 
FASC/A. 

DC/ML ~ 
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REPLACED 



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S/LME/? 

CI /PS. 



CE/?£8RM COffiX 
AMACEMTOm 

SY/V/AH f/SS(/A£> 



S/LVEP 
CI /PS. 



Fig. 44. — Diagrammatic sketch of the dural flaps replaced but not sutured so that a permanent decom- 
pression results; the silver clips can be seen clamping the dural branches of the middle meningeal artery: 
the rubber tissue drain is left in situ. Closure of the incision is now begun. 



io2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



and after sterilization these can be put in a clip holder (similar to a hemostat 
with a grooved end) and clipped upon the dural vessel. This method saves 
much time and entails no risks. 

The dural opening* is thus enlarged in a crucial or stellate manner until 
the bony margins of the decompression are reached. It is very important 
to incise the dura downwards to the very base of the skull so that the middle 
fossa of the skull can be easily and freely drained — so essential in all 
brain injuries with and without a fracture of the skull and associated with 
an edematous, swollen brain with or without hemorrhage (Fig. 44). 
Through this opening any underlying pathological lesion can be dealt with 
freely and safely ; large subdural clots may be removed in brain injuries, 
while small tumors can be removed and abscesses drained. Aided by the 



CATGUT 3Urt//?£ 
(CONT/A/UOaS PPOM~ 
B£LOW UPWARDS-) 



T£MPOP/IL 

M(/SCL£ 




- S/T//V 

' SUBa/TAA/£0(/sS 
T/SSUP 



"TP^POPPL 
PASC/A 



D/?M/A/- — 



Fig. 45. — Diagrammatic sketch of the routine use of continuous catgut suture (from below upward) 
to approximate rapidly the fibres of the entire temporal muscle in one layer over the bony opening; if the 
intracranial pressure is extreme, then interrupted catgut or silk sutures in two layers may be advisable. 

spoon-shaped spatula and a good electric headlight, the neighboring areas of 
the frontal lobe, the parietal lobe and the temporal lobe may be accurately 
explored for any cortical lesion. If the cerebral tension is very high, then 
the ipsolateral ventricle may be drained by the ventricle puncture needle ; 
all parts of the temporo-sphenoidal lobe and even the posterior por- 
tion of the frontal lobe and the lower portion of the parietal lobe can be 
accurately explored in the same manner, as in cases of suspected brain 
tumor and abscess formation. 

After the cerebral lesion has been removed or drained, or if merely the 
relief of intracranial pressure is desired, then a rubber tissue drain of 
one-quarter of an inch in width and several layers in thickness is inserted at 
the lower angle of the wound and inside the dura beneath the temporo- 
sphenoidal lobe as far as possible ; in this manner, excellent drainage is 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 103 



afforded the middle cranial fossa; a second drain of rubber tissue is fre- 
quently inserted subdurally at the upper angle of the incision. Before 
the closure of the opening, it is important that there should not remain 
any bleeding points, no matter how small; small cotton pledgets wet in 
warm saline solution are frequently sufficient in many cases of cortical 
oozing, or small pieces of the temporal muscle applied to the bleeding point 
and then compressed for a few seconds will stop a most troublesome oozing. 
When tumors are removed, then packs of sterile cotton, either dry or wet 
in warm saline solution and pressed into the cavity of the enucleated mass, 
will quickly prevent a large hemorrhage ; it is rarely necessary to let an 
intracranial packing remain in situ. 

The drain having been inserted beneath the temporo-sphenoidal lobe, the 



/NT£PPI/PT£0 
CAT6UT 



D££P£P IAY£P 
CFT£MPOPAL 
M(JSCL£ 



DUPM 
fL/lP' 




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COPT£X 



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P £/£££/? T/SSV£ 




/MT£PP(/P££D 
CATGUT OP S/i/i 
<SUWP£S 



—OPA/A/ 



Fig. 47. — The upper fibres of the tem- 
poral muscle being sutured with inter- 
rupted catgut as the second layer of 
sutures. 



Fig. 46. — The deeper fibres of the temporal muscle being 
approximated by interrupted catgut or silk sutures (from above 
downward and in two layers) in patients when the increased in- 
tracranial pressure is extreme. The dura is never resutured, 
nor could it be when the intracranial pressure is high without 
danger of damage to the underlying cerebral cortex. 

temporal muscle is now sutured (Figs. 45, 46 and 47) with continuous plain 
catgut (Nos. I and II in children and adults, respectively) ; then the tem- 
poral fascia with interrupted catgut and black silk alternately (Figs. 48, 
49, and 50), and finally the subcutaneous tissues with interrupted catgut 
(No. 1) (Fig. 51) ; the vessels of the scalp are not ligated as the mere sutur- 
ing of the subcutaneous tissues is sufficient to compress their vessels ; at times. 
the temporal artery is separately ligated. The skin is carefully approximated 
by interrupted sutures of fine black silk (Fig. 52). Dry gauze pads are 
now applied to the operative area, and after a cotton pad well covered with 
sterile vaseline is placed behind the lobe of the ear to prevent its being 
pressed against the skull and thus causing severe pain, the usual bandage of 
rolled gauze is applied and held in place by several strips of adhesive 
plaster (Fig. 53). 



io 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

In the operation of subtemporal decompression to lower an increased 
intracranial pressure, the dural opening is never sutured together; in the 
first place, if there is much intradural pressure, it would be impossible 
to approximate the edges of the dura on account of the cerebral protrusion, 



c/ireur si/tvpes 

(/A/TEPPVPTED) < 

s/i/r suti/pes <" 

(/MTEPPUPTED) 




— SK/N 



SUBCUTAJVEOl/S 
T/SSl/E 

TE/fPOPAL 
EASC/A 



— -DPA//V 



Fig. 48. — Closure of temporal fascia. Diagrammatic sketch of the routine method of using interrupted 
small black silk sutures, alternating with interrupted catgut sutures for the closure of the temporal fascia 
and thus making a firm approximation possible; the silk sutures are permanent sutures and prevent an 
opening of the incision if the catgut sutures should be absorbed too early. 



TEMPO/?/!/. 
Mt/SCLE. 




TS/iPOPAL P4SC//I. 
,/MTEPPUPTEO BLACK 
S/LK SUTURES. 

—0XA//V OP MB&ER T/SSC/E. 

Fig. 49. — Inserting the interrupted black silk sutures for the approximation of the edges of the temporal 

fascia (from below upward). 

and secondly, to resuture the dura would be to destroy the object of the 
decompression — the relief of intracranial pressure ; for in adults, the dura 
is inelastic, so that there can be no real decompression if the dura is 
unopened or resutured after being opened. There is no danger apparently 
in letting the dura remain open; adhesions do not form, and as revealed 
in three cases at autopsy, a new dura was present. The overlying muscle 
forms a safe protecting covering. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 105 



SUBCUTANEOUS FASCIA 

WITH THE _ _ I 
HEM STATS APPLIED 



X TEMPORAL 
'MUSCLE 



TEMPORAL 
'"FASCIA 




—INTERRUPTED 

/ CATGUT SUTURES 



DRAIN 



Fig. 50. — Interrupted catgut sutures to alternate with the black silk sutures in the temporal fascia. 



■S/T//V 



subcutmeovs 
tissue 



*>/NTEfi/?l/Pr£0 

c/irsur 

SUTURES 



-Dft/IM 




Fig. 51. — Closure of the subcu- 
taneous fascia. It is sutured with 
interrupted catgut; continuous 
catgut (loosely) may be used in 
children in order to hasten the 
closure in emergency conditions. 



Fig. 52. — Closure of the scalp. Careful approximation 
of the skin incision with interrupted tine black silk 
sutures; the drain of rubber tissue is allowed to remain 
in situ for one or two days, according to the amount of 
drainage of blood and cerebrospinal fluid. Sterile gauze 
dressing and bandage are now applied. 



io6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



Post-operative Treatment. — Beside the routine hospital treatment, the 
following post-operative measures are advisable : 

I. Raise the head and shoulders with two or three pillows to an elevation 
of 25 to 30 degrees ; if the shock of the intracranial injury and of the opera- 
tion is severe, then allow the patient to remain ' ' flat ' ' in bed. If the tem- 
perature should descend rapidly to 104° and higher, and especially in 
children, and in the absence of pulmonary complications, it is then advisable 
to lower the head and trunk by elevating the foot of the bed and very 
frequently the temperature will soon descend to 102 and even lower. 

II. Water by mouth as soon as the nausea ceases — both to replace the 

loss of blood and cerebrospinal fluid and 
to lessen the thirst and thereby the rest- 
lessness of many of these patients. 

III. Rectal enemata of 400 c.c. of 
warm normal saline solution immedi- 
ately, and repeated every four hours for 
at least 24 and even 36 hours. If the 
patient is in a severe condition of oper- 
ative shock, then 400 c.c. of hot black 
coffee per rectum is administered imme- 
diately after the operation, and this is 
repeated two and then four hours later, if 
deemed necessary. Formerly, urotropin, 
gr. v-x, were given in the rectal saline 
every four hours; it was believed to 
inhibit the growth of bacteria in the cere- 
brospinal fluid, and in this way, a pos- 
sible infection and meningitis were 
avoided ; its real efficacy is doubtful since 
the cerebrospinal fluid is mildly alkaline 
and urotropin is effective in only acid 
media, such as the urine, etc. ; it can, 
however, do no> harm, and it may do 
some good. 

IV. The temperature, pulse and respiration should be recorded each 
hour for twelve hours, and then every two hours for at least 36 hours; 
in this manner, the general condition of the patient is ascertained, a rare 
secondary hemorrhage or an increasing intracranial pressure affecting the 
medulla may be suspected early and the appropriate treatment immediately 
instituted ; repeated ophthalmoscopic examinations are essential. 

V. Morphia, gr. % hypodermically for restlessness, and repeated after 
one hour, if necessary. 

The room should be cool and darkened, quietness being enforced. On 
the day following the operation, liquids, except meat juices and milk, may 
be given. On the second day post-operative, the first dressing is made ; 
the drain is now removed, allowing clear or even slightly blood-tinged 
cerebrospinal fluid to trickle out; drainage of bloody cerebrospinal fluid 
and even blood itself in these patients during the first twenty-four hours 




Fig. 53. — Roller bandage of sterile gauze 
applied to the head and firmly anchored by sev- 
eral adhesive strips. A small cotton pad placed 
behind the ear lobe prevents its painful com- 
pression against the head; the opposite ear 
is not covered. 



THE TECHNIC OF SUBTEMPORAL DECOMPRESSION 107 

after operation, may be profuse and sufficient to soak through the dressings. 
At least one-third of the skin sutures can now be removed. All liquids 
except meat juices may now be given ; and, on the fourth day post-operative, 
soft diet. On the fifth day post-operative, the second dressing is made ; all 
skin sutures are removed and the patient is placed upon a light diet. The 
average duration of the hospital residence is ten to fourteen days ; no patient, 
however, should be permitted to return home unless his general condition is 
excellent and the operative area depressed or at least flush with the surround- 
ing scalp (but not tense and bulging), and thus indicating that the increased 
intracranial pressure has been relieved; ophthalmoscopic examinations of 
the fundi are very helpful in determining the gradual subsidence of the 
edematous obscuration of the details of the optic disks. 

Upon returning to their homes, these patients should not be permitted 
to lead active lives for a period of three to six months ; even the least injured 
of them are not so stable emotionally for several months as before the 
injury, and therefore it is essential for them to avoid all excitement and 
especially that of a strenuous business life ; their social and domestic activi- 
ties should be restricted to a minimum. These patients should be examined 
at frequent intervals for a year and even longer in order that no untoward 
signs should be overlooked. Their diet should be a light one with no meat, 
meat-soup, tea or coffee for at least six months ; and most important of all, 
no alcohol in any form whatsoever — the danger of convulsive seizures is 
an ever-present one on account of the increased cortical irritability of the 
brain and the after-treatment must be directed to its lessening ; many of the 
future complications possible in these patients result from the neglect of 
these precautions. A careful regulation of the bowels so that a daily 
movement occurs is also of much importance. All severe mental and emo- 
tional strains should be avoided for at least a period of one year and if 
possible for several years, 



CHAPTER IX 

Observations Regarding the Operation of Cranial Decompression 

The field of neurological surgery has so broadened during the past 
fifteen years as the result of the pioneer work of Horsley, von Eiselsherg, 
and Krause, and in this country of Cushing, that a number of neurological 
conditions that were formerly considered hopeless are now amenable to 
improvement at least, and in some early cases even a cure may be expected. 
This advance has been due chiefly to earlier diagnosis, an improved surgical 
technic and surgical judgment, and to better team-work of the surgeon 
and the neurologist. 

Earlier diagnosis of many intracranial conditions is now possible mainly 
as the result of the more general and intelligent use of the ophthalmoscope ; 
it is now commonly recognized and appreciated that the condition of marked 
papilledema and "choked disks" is the end-result of preexisting pressure 
signs observable in the fundus of the eye ; no longer is it necessary to wait 
until a measurable papilledema occurs before it can be definitely stated 
that an increase of the intracranial pressure is present. Beside the early 
fundal signs ascertainable by an ophthalmoscopic examination, the most 
accurate and definite test of an increase of the intracranial pressure is the 
lumbar puncture, using the spinal mercurial manometer; in this manner, 
the ophthalmoscopic findings can be confirmed. Intracranial localization 
has been greatly facilitated by the most thorough neurological examinations, 
and yet in many cases the localizing signs are so obscured by the increased 
intracranial pressure that they can be easily overlooked and they may even 
be absent ; the importance of examining these patients early is obvious. No 
patient should be allowed to develop a secondary optic atrophy and its 
resulting blindness while the effort is being made to localize the condition — 
an unimportant consideration in many patients; an early cranial decom- 
pression will save the eyesight and frequently the intracranial lesion can 
be localized later. Rontgen-rays are of much assistance in the diagnosis 
of many cranial and spinal lesions; by this means, long-continued intra- 
cranial pressure signs may also be determined and frequently the site of 
the lesion indicated; a negative picture, especially of the skull, however, 
means nothing, and frequently the interpretation of apparently positive 
plates is most difficult and at times confusing. Naturally, in cranial and 
spinal injuries, the value of the Rontgen-rays is very great indeed, especially 
regarding accurate diagnosis, and yet the treatment of such conditions, 
particularly of brain injuries, depends upon the presence or not of an 
increased intracranial pressure, whether the skull itself is fractured or not ; 
whereas in spinal injuries, the chief concern is whether the spinal cord has 
been irreparably damaged or not — the spinal fracture being of little impor- 
tance neurologically so far as the treatment is concerned, unless the vertebral 
dislocation is so extensive that the spinal cord must have lost its continuity. 
An improved surgical technic, especially regarding the team-work of 
1 08 



OPERATION OF CRANIAL DECOMPRESSION 109 

the operator and assistant, has been a large factor in lowering the mortality 
of neurological operations ; not only is the rapid loss of blood avoided, the 
duration of the operation lessened and thereby the shock minimized, but 
the risk of infection is also proportionately diminished to a point practically 
nil. Naturally, intracranial operations should not be hurriedly done, but 
they can be quickly and at the same time smoothly and safely performed ; 
there is surely no advantage to be obtained in prolonging the operation 
either on account of faulty technic or as a result of such a complicated 
technic that the final closure of the wound is delayed many minutes. It 
is rarely necessary for the team to consist of more than the operator, two 
assistants and a nurse; the anesthetist is a most important member and 
many disasters in cerebral surgery have been due to faulty anesthesia; 
Doctor Hunt's observations have resulted in his using a method of ether- 
oxygen that has proven most satisfactory during the last six years. 

The third important factor in the progress of neurological surgery 
during the past decade has been due to a better understanding of the 
neurological condition at operation, both by the surgeon and by the neurolo- 
gist at his side. Formerly, the surgeon knew little, if any, neurology, and 
the neurologist knew little, if any, surgery ; the result was poor team-work 
and thus frequently the surgical judgment was not the best. A number 
of years ago, Dr. Allen Starr realized this so that in many patients he 
really performed the operation himself except the actual handling of the 
instruments ; those operators who were not so fortunate to have a competent 
neurologist by their side groped along and frequently much damage 
resulted. To-day the surgeon should have at least a practical knowledge 
of neurological principles — both anatomically and physiologically; natur- 
ally, a training in neurological pathology is most essential. In this manner 
a number of mistakes in surgical judgment may be "avoided; if the patient 
cannot be benefited, by no means make the condition worse by an operation. 

One of the most important aids to an increased knowledge of neurological 
lesions, particularly of the brain and of the spinal cord, has been the 
observation of the living pathology at operation, and if death should occur, 
then the careful study of the tissue itself at autopsy. During the last 
five years, a permission for autopsy has been obtained before operation in 
each case 1 of neurological surgery at the Polyclinic Hospital (both ward and 
private patients) — no operation being performed unless the permission is 
given in writing, so that if death should occur, then we shall ascertain its 
cause, and also the accuracy of the diagnosis and the treatment for the 
benefit of future patients. Naturally, when an operation is advised, it is 
in the belief that the patient will not die, but if the patient should die, then 
it is absolutely essential for the benefit of other patients that we ascertain 
the cause of death in order that possible similar mistakes, at least, may be 
avoided. I know of no means so enlightening to the doctor regarding the 
accuracy of diagnosis, particularly of intracranial conditions, than the 
post-mortem examination; besides the benefit of such knowledge to one's 
future patients, there is a marked tendency for these examinations to 
make the doctor humble as to his real knowledge and to keep him in that 
mental attitude. 



no DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

If neurological surgery consisted chiefly of the removal of brain tumors, 
it would indeed be a most discouraging field of endeavor. Tumors of the 
brain are not only malignant in the vast majority of cases, but the diagnosis 
and accurate localization of cerebral tumors are often so delayed that the 
patients are frequently permanently impaired even after a surgically suc- 
cessful removal of the tumor; in addition to the mental and physical 
impairment, the danger of a secondary optic atrophy, with the varying 
degrees of impaired vision and even blindness, is a very common result of 
the prolonged increase of the general intracranial pressure. Naturally, the 
earlier a definite diagnosis of the tumor is made the better the prognosis. 
With the improved surgical technic and plan of attack in these patients, 
the operative mortality is low ; when death does occur after operation, it is 
usually due to an attempt to do too much rather than perform a second 
stage operation at a later date. Besides these removable tumors of the 
brain, there are the so-called inaccessible tumors, situated at the base of the 
mid-brain ; the pioneer work of Doctor Cushing in attacking the Irypophyseal 
tumors by the sublabial, septal and transsphenoidal route is most brilliant ; 
it is limited, however, to cases of primary pituitary tumor affecting the 
overlying optic chiasm and thus producing a primary optic atrophy ; tumors 
of the mid-brain, which are much more common, cannot be approached by 
this method and it is rare that they can be successfully removed by any 
method now ^sed ; to offset their pressure effects by means of the operation 
of cranial decompression and thus delay the secondary optic atrophy is the 
most that can be hoped for in many patients. 

There are few operations in surges having the wide application and 
immediate beneficial results as the cranial decompression, and particularly 
the subtemporal method. It is an operation that has been very much 
neglected in the past and one that is capable of still greater usefulness in 
the future. It is a comparatively simple operation, requiring no special 
technic other than a thorough knowledge of the anatomy of the temporal 
region and the avoidance of operative complications ; if, however, difficulties 
are encountered, then the use of the best methods for controlling them. 
Naturally, careful hemostasis is a most important factor in obtaining- 
good results in all cranial operations ; due respect and regard for the delicate 
nerve cells of the cerebral cortex by the avoidance of unnecessary and rough 
manipulation and digital examination of it ; and, of the greatest importance, 
a most strict asepsis. 

Cranial decompressions have been limited in the past chiefly to the relief 
of intracranial pressure in cases of unlocalized cerebral tumor, and in 
patients having a "fracture of the skull" and showing signs of medullary 
compression; the operation was performed net only to lessen the danger of 
a medullary edema, but to avoid a secondary optic atrophy so commonly 
observed in tumors of the brain. In these latter patients, the site of the 
decompression was most frequently over the parietal area or the upper 
temporal region, and thus, as the tumor enlarged, the increasing intracranial 
pressure forced the underlying cerebral tissue through the bony opening, 
producing a hernia cerebri of tremendous size — the bane of cranial surgery ; 
a fungus cerebri was also a common result of such protrusion. Not only was 



OPERATION OF CRANIAL DECOMPRESSION in 

this complication to be feared, but the operative danger to the underlying 
motor area with resulting paralysis of the opposite side of the body was 
always risked; besides, the intracranial pressure in "fractures of the skull," 
as well as in tumor formations, frequently produced a motor impairment by 
forcing the motor area upward through the bony ring of the decompression. 

The reason for these complications is obvious: to remove an area of 
either parietal bone, not only may the underlying motor cortex be impaired 
at the time of the operation but also subsequently by its protrusion upward 
through the bony opening; this is made possible by the extremely weak 
protection afforded by the scalp overlying the parietal bone; besides the 
cutaneous tissues in this area, there is only the epicranial aponeurosis, 
so that even a moderate degree of intracranial pressure is sufficient to cause 
a hernial protrusion. If the decompression's performed in the lower parietal 
area, then the cranial origin of the temporal muscle to the parietal crest 
must be destroyed and thus the possible protection of the temporal 
muscle is lost. 

In contrast to these methods of cranial decompression, the subtemporal 
route offers an almost ideal operation for intracranial conditions requiring 
either a relief of the increased pressure or an exploratory procedure ; not 
only is the underlying cortex here a part of the temporo-sphenoidal lobe 
(which is a comparatively "silent" area of the brain), but the removal of 
the squamous bone is technically less difficult in that it is the thinnest part 
of the vault of the skull. Again, the decompression opening is amply pro- 
tected by the overlying temporal muscle, so that it is a very rare occurrence 
to have a hernia cerebri following this method of cranial decompression; 
if the attachment of th*e temporal muscle to the parietal crest is carefully 
preserved, then it is practically impossible for a marked protrusion to occur ; 
in my opinion, this method of decompression should be the one always to be 
employed. In subtentorial lesions affecting the cerebellum, naturally a 
suboccipital decompression is to be preferred ; especially is this true of 
tumor and abscess formations in it. As the tentorium strongly separates 
the cerebellum, any increase of the subtentorial pressure is more effectively 
relieved by a suboccipital decompression than by a supratentorial operation ; 
besides, not only may the lesion be removed at the same time, but the bony 
opening will be protected by the thick layer of occipital muscles and thus 
a large hernia be prevented. 

The purpose of the subtemporal decompression has been very much 
enlarged during the past few years, and it seems that its usefulness is to be 
developed still more in the future. Although its chief function is the 
relief of intracranial pressure, yet it is a most valuable method of explora- 
tion. In these two divisions, practically all of the intracranial conditions 
for which the operation may be advisable, can be classified. 

The operation of cranial decompression has been so frequently misin- 
terpreted, and even confused with other cranial operations, that it seems 
advisable to state its indications and contraindications, and to describe 
the type of decompression, with its most satisfactory technic. 

As is indicated by the name of the operation, a cranial decompression 
presupposes the presence of an increased intracranial pressure: if there 



ii2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

is not present an increased intracranial pressure, then the operation cannot 
be described as a decompression, but rather as a craniotomy (if the bone- 
nap is replaced), or a craniectomy (if the bone-flap is permanently re- 
moved). In the recent literature, the term decompression is commonly used 
to indicate merely a trephine opening, and in many instances the dura not 
even opened or allowed to remain open; surely a small trephine opening 
in itself with the dura opened may theoretically be to a certain extent, 
a decompression, but its decompressive effect is practically almost negligible ; 
again, to replace a bone-flap even though the dura is allowed to remain open 
is not a decompression, because the decompressive effect of the operation 
is nullified. It would seem, therefore, that the three qualifications essential 
to a cranial decompression (in order that it be correctly considered as 
such) are: 

1. The presence of an increased intracranial pressure. 

2. The removal of a large area of the vault — usually 3 inches in diameter. 

3. The dura to be opened and allowed to remain open; as the dura is 
inelastic in adults, no decompressive effect can be obtained unless the dura 
is opened, and if a permanent decompression is desired, then the dural 
opening must not be resutured but allowed to remain open. 

Cranial decompressions were commonly performed in the past over 
the upper areas of the vault. Many disasters resulted from this procedure ; 
in fact, the operation of cranial decompression for this reason was practi- 
cally discredited and it remained an operation of the last resort until 
Gushing placed the operation upon a rational basis. In patients having 
a marked increase of the intracranial pressure as in brain tumor, not only 
was the operative damage to the underlying, highly developed cerebral 
cortex a frequent result of such decompressions situated over the upper 
portions of the vault and thus followed by paralyses, impairment of the 
special senses, and only too frequently the immediate death of the patient, 
but the insecure closure of the operative wound (merely covered by the 
scalp ) permitted huge hernise cerebri to occur and only too frequently their 
end-result, fungi cerebri and the death of the patient after months of a 
vegetative existence. It is no surprise therefore, that a few years ago the 
operation of cranial decompression was avoided as long as possible — even 
at the risk of the delay producing an impaired vision and even blindness 
itself, and it is this transmitted dread and fear of cranial operations thac 
has retarded the development of brain surgery possibly more than any other 
factor. Cranial operations as now performed are no longer such extreme 
risks, while the operation of cranial decompression is in itself no greater 
risk than the usual abdominal operation. This advance is due chiefly to 
better team-work of the surgeon and the neurologist, a more practical con- 
ception of the purpose of the operation of cranial decompression, and then 
a most important factor, an improved surgical technic. 

The operation of cranial decompression may be considered as a means 
solely of decompression, then of decompression plus exploration, and lastly, 
of decompression plus drainage. The following intracranial conditions 
as benefited by the operation of decompression may be classified briefly 
as follows: 



OPERATION OF CRANIAL DECOMPRESSION 113 

A. Decompression alone. 

I. Brain tumors 

1. Irremovable tumors. 

a. Large midbrain and basal tumors. 

b. Large subcortical tumors, the removal of which would 

produce grave impairments, such as paralysis. 
II. Selected cases of cerebral spastic paralysis due to an intracranial 
hemorrhage at birth. 

B. Decompression and exploration. 

I. Brain tumors — non-localizable tumors, usually situated in the 
frontal and temporo-sphenoidal lobes. 
II. Brain abscesses — non-localizable abscesses — usually situated in 
the temporo-sphenoidal lobes. 
III. Selected cases of organic epilepsy — Jacksonian in type or asso- 
ciated with increased intracranial pressure. 

C. Decompression and drainage. 

I. Brain injuries with or without a fracture of the skull. 
II. Hydrocephalus — either of the internal or of the more common 
external type. 
III. Brain abscess. 
IV. Early localized meningitis especially due to otitic infections. 

There are several other intracranial lesions for which the operation of 
cranial decompression has recently been advocated, notably the condition 
of apoplexy. It is possible in rare and selected cases of cortical apoplexy 
alone, and at times in ventricular hemorrhage (although the diagnosis and 
operative drainage should be almost immediate in order to have the patient 
survive) that the operation of cranial decompression and drainage might 
be considered in order to obtain the greatest ultimate improvement, but to 
advise this operation for the usual form of apoplexy — the internal capsular 
type, which occurs in 90 per cent, of these patients is a most unsurgical 
procedure ; not only do these latter patients not have an increased intra- 
cranial pressure, unless the hemorrhage is of unusually large size, and 
therefore the operation described in the literature cannot be a decompression, 
but the operative damage resulting from the attempt (and it can only be 
a blind attempt) to insert a needle into the internal capsule and thus drain 
the hemorrhage (even if it would drain) would be far greater than the 
impairment caused by the lesion itself ; besides, some of the reported patients 
have been operated upon late, when no drainage of the hemorrhage would 
be possible ; and even in the early cases operated upon, it must be remembered 
that the hemorrhage into the internal capsule is rarely a free one. but is 
enmeshed among the capsular fibres, giving the appearance almost of liver 
tissue, and surely such hemorrhage cannot be drained. To advise, therefore, 
a cranial operation upon such patients merely because medical treatment 
has not caused a marked improvement is surely not rational surgery. 

There may be selected cases of acute cerebral edema due to such toxic 
causes as occur in uremia and certain other toxic conditions where, after 
medical treatment has failed, a cranial decompression might be advisable to 
8 



ii4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

lessen a high intracranial pressure, and thus to a certain extent, spare the 
vision and avoid a medullary compression and its resulting edema — always 
fatal. No cranial operation, however, should be considered in these patients 
until repeated lumbar punctures have been proven inadequate. This work, 
however, is only in the experimental stage, and must be considered as a 
possible aid only in very selected patients. 

The cranial decompressions of choice are the subtemporal decompressions 
for supratentorial lesions and the suboccipital decompressions for infraten- 
torial lesions. Naturally, the subtemporal decompression as a decompres- 
sion alone is of little or no benefit for infratentorial lesions and should 
never be used in such conditions unless as a means of ventricular drainage 
(in cases of ventricular blockage) ; infratentorial lesions such as cerebellar 
tumor and abscess are always more effectively treated by the suboccipital 
operation of decompression, exploration and drainage. In this book, how- 
ever, the term cranial decompression means the subtemporal operation — the 
most satisfactor}' and effective method of decompression for supratentorial 
lesions; the vertical incision alone is used. (The advantages of this method 
of cranial decompression are detailed at the end of this chapter.) 

Let us consider briefly the three main purposes of the subtemporal 
decompression : 

A. Primarily as a Means of Lessening an Increased Intracranial Pres- 
sure. — I. Brain tumors. As the percentage of malignancy in brain tumors is 
high (almost 80 per cent.), they naturally form a very discouraging part 
of brain surgery ; then again, if the tumor is not malignant in itself, yet it 
may be so situated in the mid-brain or base that to remove it would either 
cause the immediate death of the patient or such a marked mental, physical 
or sensory impairment that it would not be justifiable ; that is, the condition 
of the patient might be worse than before the operation. It is not credit- 
able to brain surgery to remove the tumor (even if benign) if the mental 
and physical condition of the patient is worse than before the operation — 
the patient remaining a derelict. 

It is in these very patients that, in order to lessen the headache and 
to save the vision, an early subtemporal decompression on one side and, if 
necessary, on both sides of the skull is most strongly to be advocated. Not 
only will the general condition of the patient be improved and blindness 
avoided, but the tumor may not continue to enlarge and may remain station- 
ary and even become smaller apparently, and thus the patient be spared 
indefinitely ; this is particularly true in young adults — the diagnosis being 
a tuberculoma of the mid-brain; the edematous wet brain of the so-called 
pseudo-tumors might be also included. To allow these patients with a 
high degree of "choked disks" to develop a secondary optic atrophy and 
its resulting blindness merely because the tumor is considered an irremovable 
one or cannot be localized is an opinion that cannot be too strongly con- 
demned. The operation of cranial decompression is no longer such a for- 
midable procedure that it should be delayed and postponed until the life 
itself of the patient is endangered ; to operate upon these patients blinded 
by long-continued intracranial pressure is most depressing and possibly 
hardly justifiable. 



OPERATION OF CRANIAL DECOMPRESSION 115 

II. Selected cases of cerebral spastic paralysis due to an intracranial 
hemorrhage at birth. These patients were formerly classed in that large 
group due to Little 's disease and thus confused with cases of lack of develop- 
ment of the cerebral cortex and its pyramidal tracts, and also with those 
cases resulting from a former meningo-encephalitis — an infectious destruc- 
tive process and, naturally, conditions which cannot be benefited by any 
cranial operation. But patients having a spastic paralysis due to an intra- 
cranial hemorrhage at birth not only can be differentiated by the presence 
of an increased intracranial pressure as ascertained both by the ophthalmo- 
scope and more accurately by a measurement of the pressure of the cerebro- 
spinal fluid at lumbar puncture by means of the spinal mercurial manometer, 
but those latter patients can be markedly improved by a lessening of this 
increased pressure by means of a simple subtemporal decompression. Natur- 
ally, only those patients having an increased intracranial pressure can be 
benefited and are therefore the only ones that are operated upon; out of a 
series now, January, 1918, of almost 1800 patients that I have personally 
examined, only 378 of them revealed the presence of an increased intracranial 
pressure — that is, about one out of every five patients examined — and these 
are the only ones for whom a cranial decompression can be of any benefit. The 
best results are obtained when the condition is diagnosed at the time of birth 
or shortly after it — and it very easily can be by the presence of blood under 
pressure in the cerebrospinal fluid at lumbar puncture ; then, a modified 
cranial decompression with drainage of the free hemorrhage will in many 
cases obtain a normal child. (Even repeated lumbar punctures with drain- 
age may suffice if the intracranial hemorrhage is not too large and the 
pressure too high; in these latter cases of high intracranial pressure the 
cranial operation of opening the parieto-squamous suture combined with 
a modified subtemporal decompression and drainage is advisable ; the dura 
must always be opened.) The older the child the less is the improvement 
that can be ultimately obtained by the operation of merely lessening the 
increased intracranial pressure resulting from the earlier hemorrhage ; 
frequently a mild secondary external hydrocephalus results in these patients 
from the blockage of the stomata of exit of the cerebrospinal fluid in the 
cortical veins and sinuses ; this condition can be drained accordingly at the 
same time by a modified decompression operation {vide Hydrocephalus). 

The pathology of intracranial hemorrhage in these patients is very in- 
structive. It was formerly believed that the hemorrhage always caused 
a primary destruction of brain tissue and, therefore, no regeneration being 
possible, that these patients were all hopeless. As a permission for a post- 
mortem examination is obtained before operation upon each patient, it has 
been very surprising to ascertain, either at the operation or at autopsy, 
that the intracranial hemorrhage caused a primary destruction of brain 
tissue in only 26 patients out of 364 patients operated upon ; that is. in only 
7 per cent. The death-rate of these operations was only 38 out of the series 
of 374 operated patients — that is, a mortality of only 10-f per cent. — and a 
post-mortem examination was made in each ease. The hemorrhage is almost 
always a supracortical one with later cystic formation, so that the mental 
and physical impairments in these patients are due to the increased pressure 



n6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

of the overlying lesion — both a general and a localized increase of the intra- 
cranial pressure. It is the lessening of this increased intracranial pressure 
in these selected patients that permits a marked improvement in them, both 
mentally and physically. 1 

B. Decompression Plus Exploration. — I. Brain tumors. Infraten- 
torial growths are more easily localized than are the ones situated above the 
tentorium, so that if the former cerebellar tumors can be excluded, then it 
is a question of ascertaining the cerebral hemisphere in which the lesion is 
placed ; at times, the clinical signs point very clearly to the location in the 
hemisphere, and yet only too frequently it cannot be definitely and accur- 
ately elicited. These are the patients who should not be permitted to 
develop a secondary optic atrophy and even blindness itself while an 
accurate localization in the hemisphere is being sought; an early subtem- 
poral decompression will not only lessen the intracranial pressure but it 
will afford a practical means of locating the lesion by exploratory punc- 
tures — it being possible to explore carefully the entire ipsolateral hemis- 
phere. If the tumor is found (and it very frequently is found in the com- 
paratively silent area of the temporo-sphenoidal lobe directly beneath the 
subtemporal incision so that it can be removed immediately), then the 
proper method of removal can be used, and if the tumor is not found (also, 
unfortunately, a frequent occurrence), then a decompression has at least 
been performed, the headache improved and the vision spared so that a 
later localization of the tumor may occur and its removal be possible and — 
the patient not blind. The lateral ventricle may also be tapped with a 
ventricular puncture needle to ascertain whether it is dilated or not; if 
dilated, then the tumor would necessarily be either basal posteriorly or 
even subtentorial ; ventricular drainage temporarily might be instituted 
to improve the general condition of the patient until the tumor, if subten- 
torial, could be removed. To perform large osteoplastic ' ' flap ' ' operations 
over the parietal lobe in search of a tumor which may not be present even 
in the underlying hemisphere, and if present, then possibly at the base or 
in extreme frontal or occipital portions, and very frequently in the lower 
portion of the temporo-sphenoidal lobes — situations requiring another incis- 
ion and removal of bone in order to approach the tumor — such tremendous 
bone-flap operations should never be performed unless it is surely known 
that the tumor can be removed through the incision; if the tumor is 
not found and the intracranial pressure is high, then great difficulty 
will be encountered in making a firm enclosure without causing a definite 
damage to the more high developed parietal cortex; in these patients a 
simple subtemporal decompression would permit an accurate localization 
of the tumor — whether frontal, occipital, parietal, temporo-sphenoidal 
or basal — and then the tumor could be later removed through the appro- 
priate incision. 

II. Brain abscess. The great majority of brain abscesses are cerebral 
and situated usually in the temporo-sphenoidal lobe adjacent to the ear in- 
volved — otitic disease being the most common cause of brain abscess forma- 
tions. As in brain tumors, infratentorial cerebellar abscesses are more easily 

1 International Clinics, 1917, iii, Series 27. 



OPERATION OF CRANIAL DECOMPRESSION 117 

diagnosed than the supratentorial temporo-sphenoidal ones, so that if cere- 
bellar abscess can be excluded, then the operative approach of choice is 
through the ' ' clean ' ' subtemporal area and not through the ' ' dirty ' ' infected 
field of the mastoid incision; all drainage operations for brain abscess are 
really exploratory procedures, as the abscess may not be present or not 
found, and if the dural incision has been made through the infected mastoid 
area then the danger of causing a diffuse meningitis is very great indeed. 
If, however, the subtemporal exposure has been made and if the abscess is 
not found, then at least a decompression has been performed and the danger 
of a meningitis is slight ; and if the abscess is found, then it can be freely 
and safely drained through the lower angle of the subtemporal incision. Not 
only does the decompression incision afford better drainage for the deeper 
subcortical abscesses by means of the double glass tubes, but the opportunity 
afforded of locating these deep abscesses is much greater and easier through 
the wider exposure of the decompression incision. 2 

III. Selected cases of epileptiform convulsions — Jacksonian in type or 
associated with an increased intracranial pressure. The surgical treatment 
of organic epilepsy is most discouraging, and no cranial operation should 
be ever advised in cases of long standing in the belief that the condition can 
be cured. In only very selected cases of short duration where the attacks 
are definitely of the Jacksonian localizing type and where there is a marked 
increase of the intracranial pressure (still persisting after an interval of at 
least three months has elapsed since the last attack), is the operation of 
cranial decompression and exploration or any cranial operation justifiable ; 
even in the most carefully selected cases the results are not encouraging, and 
yet good result and apparently even a cure is occasionally obtained in these 
patients. Cranial surgery, however, cannot be said to offer much hope to 
these patients, except possibly to these very early selected patients as 
described above. To operate upon old chronic cases of whatever severity 
is hardly justifiable. Even the removal of the primary cause of the cor- 
tical irritation with its resulting convulsions — such as cortical tumor, old 
depressed fractures of the vault and the cyst formation due to a former 
supracortical hemorrhage, may result in only a temporary cessation of the 
convulsions in the older patients; but these patients should be diagnosed 
early, the irritating lesion removed and then the outlook is not so gloomy ; 
besides removing the lesion itself, it is always wiser in these patients to 
relieve permanently the intracranial pressure due to the resulting cerebral 
edema of trauma by means of a subtemporal decompression. 

C. Decompression Plus Drainage. — I. Brain injuries with or without 
a fracture of the skull. The mortality of brain injuries with or without 
a fracture of the skull has been notably decreased within the past decade ; 
the former death-rate of 50 per cent, and even higher lias been reduced in 
several hospitals to 30 per cent, and even lower. This marked improvement 
is due to a more general appreciation of the important factor of increased 
intracranial pressure in these patients and if present, then the most satis- 
factory method of relieving it by means of the subtemporal decompression. 

2 The Laryngoscope, St. Louis. March, 1014. 



n8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

As is well known, it is not the fracture in these patients, nor the hemorrhage 
in itself, that is so dangerous, but rather the presence of a high intracranial 
pressure — whether due to hemorrhage or edema, and its consequent medul- 
lary compression and the only too frequently resulting medullary edema — 
that renders these cases so serious — not only as to life but also as to their 
future normality. 

Formerly, the treatment of these patients had 'been so discouraging -that 
it became a commonly accepted belief that they would all "get along just 
as well without operation as with operation." This statement is perfectly 
true for over one-half of the patients — there being no increased intracranial 
pressure in practically this percentage, and naturally no operation (except 
in depressed fractures of the vault) would be indicated ; but of the remaining 
patients upon whom a cranial operation was performed, the resulting high 
mortality — in many hospitals being 80 per cent, and even higher — was due 
chiefly to the operative method used — in almost all cases the extensive osteo- 
plastic ' ' flap ' ' operation being performed and the dura very frequently not 
even being opened (and therefore no real decompression possible) or a small 
and totally inadequate trephine opening — the size of a one-half dollar piece 
and even smaller being considered as a sufficient operative procedure — these 
two operative extremes — the former tremendous operation of great risk to 
these seriously injured patients and the latter so-called operation of no pos- 
sible, or if possible, then of very slight benefit to the patients — these two 
operations were usually performed either during the period of initial 
shock within a few hours after the injury, when it is now realized that no 
operation should ever be performed as it is merely an added shock to the 
patient and takes away the patient's chance of surviving the shock, or the 
operation was performed during the terminal period of medullary edema 
in the hope that the patient would be given a chance to recover; these 
patients when they have once reached this stage all die — operation or no 
operation. Naturally, under these conditions, the operative mortality was 
very high. More recent observations, however, in a series of almost 500 
patients, have confirmed a growing belief in the following cardinal principles 
regarding the treatment of brain injuries 3 with or without a fracture of 
the skull: 

1. All depressed fractures of the vault should be elevated or removed 
for fear of later complications, particularly epilepsy. 

2. The presence of a fracture in patients having brain injuries is not 
an important factor in their treatment ; the patients most seriously injured 
very commonly have no fracture at all, and conversely, the less serious of 
brain injuries are frequently associated with tremendous linear fractures 
of the vault — an important channel, however, of lessening an increased 
intracranial pressure by the drainage of free blood and excess cerebro- 
spinal fluid or edema, and thus a cranial operation be avoided. Naturally, 
basal fractures into the middle ear and especially into the nasal and 
pharyngeal cavities may permit an infective meningitis, and yet this grave 
complication is comparatively rare. 

3. The expectant palliative medical treatment of quiet, ice helmet, 
3 J. Am. 31. Assn., May 13, 1916, lxvi, pp. 1536-1540. 



OPERATION OF CRANIAL DECOMPRESSION 119 

catharsis and liquid diet is sufficient for over one-half of the patients having 
little or no increase of the intracranial pressure. 

4. A marked increase of the intracranial pressure (as revealed in slightly 
over one-third of these patients by the ophthalmoscope and the measure- 
ment of the pressure of the cerebrospinal fluid at lumbar puncture by means 
of the spinal mercurial manometer) and not by the late and extreme pressure 
signs of medullary compression (such as a pulse-rate of 50 and lower, Cheyne- 
Stokes respiration and pulse, a high blood-pressure and profound uncon- 
sciousness) should be lessened by a cranial decompression and drainage — 
not necessarily at the site of the fracture if present, and by no means over 
the upper cortical areas, but rather by means of the subtemporal decom- 
pression — the safest and most effective means of decompression, drainage 
and closure possible in these patients. The dura must always be opened 
(except in the cases of simple extradural middle meningeal hemorrhage, 
which are rare) and allowed to remain open for a permanent decompression 
and drainage of the consequent traumatic cerebral edema so common in 
these patients. If the intracranial pressure is extremely high, then a 
bilateral subtemporal decompression and drainage may be necessary — 
apparently in about 5 per cent, of the patients. 

5. There are two periods in the treatment of these patients when no 
operation is advisable, no matter how seriously the patient is injured nor 
how high the intracranial pressure may be; these periods are — first, the 
stage of initial shock immediately following the brain injury when the 
pulse-rate is 120 or higher ; any operation during this period of traumatic 
shock is merely an added shock to the patient and takes away the patient's 
chance of surviving the shock ; if, however, he does survive the shock, then 
he does so in spite of the operation; and the second period in which no 
operation should be performed is the stage of medullary edema — the ter- 
minal moribund period — operation or no operation ; when once the pulse has 
reached its lowest level of medullary compression and then begins to 
ascend rapidly to 100, 120, 140 and higher, then an operation does not 
"give the patient a chance" (as formerly advocated), but merely hastens 
the exitus. If these two periods in the operative treatment of brain injuries 
are avoided and the latter of these — medullary edema — usually can be 
anticipated, then the mortality of brain injuries will be decreased to 30 per 
cent, and even lower, while the operation of decompression and drainage 
will make possible not only the recovery of patients as to life but also as to 
their future normality. 

II. Hydrocephalus, both of the internal and also of the more common 
external type. A diffuse meningitis is the usual primary cause of this 
condition; if the ventricles are blocked by exudate or adhesions in the 
aqueduct of Sylvius or at the foramina of Majendie and Luschka. then the 
internal type of hydrocephalus results, but if this ventricular blockage does 
not occur, yet a hydrocephalus of the external type develops because the 
cerebrospinal fluid cannot be excreted as normally into the cortical veins and 
sinuses on account of their blockage by the former meningeal exudate. 

In the operative treatment of hydrocephalus, either of the internal or of 
the external type, it is obvious that to drain merely the blocked cerebrospinal 



120 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

fluid of the ventricles into the subarachnoid or subdural spaces, by means 
of corpus callosal punctures or tubes, would, even if these openings remained 
patent, only change an internal hydrocephalus into an external one — with 
resulting little, if any improvement. The object, therefore, of all operative 
procedures in these patients is to drain continuously and permanently the 
blocked cerebrospinal fluid beyond the cerebrospinal canal — that is, into 
the blood stream (the ideal method and not yet practicable permanently) or 
into the extradural tissues, such as the subcutaneous tissues of the scalp, rich 
in lymphatics. The subtemporal decompression permits such drainage of 
the ventricles when blocked and of the subarachnoid and subdural spaces 
in the more common type of external hydrocephalus by means of several 
linen strands extending from the ventricles outward through the temporal 
lobe (a comparatively silent area), and from the subarachnoid and sub- 
dural spaces outward beyond the opened dura into the subcutaneous tissues 
of the scalp in a stellate manner. 4 At present, this method of drainage 
through the subtemporal decompression assures an excellent drainage to all 
but apparently the most severe types of complete blockage of internal hydro- 
cephalus; naturally, the earlier the operation is performed following the 
development of the hydrocephalic condition, the greater is the chance of the 
child to approximate normality. 

III. Brain abscess. As stated above, the usual type of brain abscess 
situated in the contiguous temporo-sphenoidal lobe following otitic disease 
is most safely and effectively drained through the lower angle of a ' ' clean ' ' 
subtemporal decompression by means of double glass tubes, so that the 
inner tube may be used to drain the abscess while the outer tube remains 
always in situ, and thus the abscess, when once found, is not lost. Appar- 
ently, a large decompression opening tends to lessen the danger of a compli- 
cating meningo-encephalitis — almost always fatal, whereas the opening 
through the " dirty" field of the mastoid not only increases the danger 
and lessens the opportunity of a careful exploration of the adjacent brain 
in search of the abscess, but it does not provide a satisfactory and efficient 
drainage for the deeper subcortical brain abscesses ; again, to puncture the 
dura blindly Avith a knife through the mastoid opening or any dural expos- 
ure is most unsurgical. 

IV. Early localized meningitis. Similar to brain abscess formations, 
localized meningitis most frequently results from preexisting otitic and sinus 
disease ; cranial fractures are also another common cause. Here again, in 
the early patients, in whom lumbar punctures do not reveal the presence 
of an active organism in the cerebrospinal fluid and therefore indicating 
that the meningeal infection has not yet become a diffuse process, the opera- 
tion of subtemporal decompression and drainage will offer a definite chance 
of recovery — although the prognosis is most unfavorable ; it seems that in 
only the early and still localized conditions of purulent meningitis will 
the operation be of any benefit. 

The technic of the operation of cranial decompression has been de- 
scribed briefly in the preceding chapter ; the vertical incision and not the 
former curved one is most satisfactory. The main advantages of the sub- 
temporal decompression are the following : 

4 American Journal of the Medical Sciences, April, 1917, Vol. cliii, p. 563. 



^m 



OPERATION OF CRANIAL DECOMPRESSION 121 

1. It exposes, as widely as necessary, a comparatively "silent" area of 
the brain, the temporo-sphenoidal lobe, and therefore any operative damage 
to the exposed cortex will not appear clinically; also, in patients having 
a high intracranial pressure the danger of a hernial protrusion of a highly 
developed area of the brain with resulting paralysis, etc., cannot occur. 

2. Being situated midway between the frontal and occipital lobes, it 
permits the careful exploration of all parts of the ipsolateral hemisphere ; 
ventricular puncture, as well as permanent drainage, is also possible. 

3. It exposes the area of the middle meningeal artery so frequently 
injured in the traumatic cases, and also affords excellent drainage to the 
middle cranial fossa at its lowest point — a very important factor in the 
treatment of brain injuries. 

4. A firm closure of the decompression opening is obtained by means of 
the strong temporal muscle and its overlying fascia with their strong attach- 
ment to the parietal crest intact — a most important requisite in patients 
having a high intracranial pressure ; hernial protrusions with their frightful 
fungi are most rare. 

5. Technically, the operation is less difficult than other cranial operations 
in that the skull opening is made through the thinnest area of the vault — 
the squamous portion of the temporal bone. 

6. The vertical incision is preferable to the former curved one in that 
it renders more possible a careful hemostasis of the scalp by means of the 
method of bi-manual pressure-traction and the clamping of the main branch 
of the temporal artery at the very beginning of the operation, whereas the 
curved incision passes through the various branches of the vessel in the 
scalp and they must be clamped individually; again, the vertical incision 
not only permits drainage at the lowest point of the skull, but it makes pos- 
sible a large subtemporal bony opening without risk of loosening the attach- 
ment of the temporal muscle and fascia to the parietal crest, and thus a 
firm closure with no danger of cerebral hernia is assured. 

7. The great frequency of temporo-sphenoidal lesions such as tumors, 
abscesses, and brain injuries make this routine exposure of the subtemporal 
decompression a most important aid in the treatment of underlying intra- 
cranial lesions. 

Conclusions 

The operation of cranial decompression is one that should be used much 
more frequently than it is at present; especially is this true in the con- 
ditions of brain tumor, brain abscess, brain injuries and in selected cases 
of spastic paralysis due to an intracranial hemorrhage at birth. 

The subtemporal method of cranial decompression is the ideal route: 
besides being less difficult technically, it exposes an area of the brain most 
frequently involved. This permanent decompression opening does not 
weaken the skull in that the thick overlying temporal muscle protects it 
most adequately, so that hernial cerebri are not to be feared. 

The operative mortality is low. Patients with intracranial conditions 
should not be permitted to become blind or to reach the dangerous stage 
of medullary compression without a subtemporal decompression being per- 
formed early. (See Plates T-VITI.) 



122 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



MOVING PICTURES OF THE OPERATION OF RIGHT SUBTEMPORAL 
DECOMPRESSION AND DRAINAGE 

The patient was an alcoholic cab-driver of forty-six years of age, who was brought to 
the hospital in the ambulance following a fall from his driver's seat ; unconscious ; 
profuse discharge of blood and cerebrospinal fluid from the right ear. Repeated 
examinations disclosed the signs of a high intracranial pressure as registered by the 
ophthalmoscope and the spinal mercurial manometer and also by the gradual descent 
of the pulse- and respiration-rates, so that a right subtemporal decompression and 
drainage was performed ten hours after the injury. An irregular linear fracture of 
the right squamous bone had torn the right middle meningeal artery, causing a small 
extradural hemorrhage; the dura w r as tense and bluish, and upon incising it, a large 
amount of supracortical hemorrhage escaped, permitting the bulging cerebral cortex 
to recede and to pulsate normally. Usual closure with drainage. Excellent recovery. 

THE INCISION OF THE SCALP; METHOD OF ASEPSIS AND HEMOSTASIS 

A. Outlining the superficial skin incision from the zygoma upwards to the parietal 
crest — and not beyond. The head has been prepared in the usual manner for the 
operation; ether-oxygen apparatus in position. 

B. Two layers of sterile gauze placed over the operative area and the sterile 
towels fastened to the scalp by the towel clips. 

C. Cutting the sterile gauze layer with scissors and exposing the scalp incision 
only — and not the surrounding scalp. 

D. Field of operation prepared with the scalp incision exposed. The danger of 
infection is now practically nil. 

E. Applying the bimanual-pressure-traction method of hemostasis: the left hand 
of both the operator and his assistant used to compress the scalp vessels upon each 
side of the incision, and the assistant's right hand used to compress the temporal 
artery at the lower angle of the incision as shown in the following picture. 

F. Using the scalpel to make the scalp incision down to the temporal fascia — the 
method of hemostasis by bimanual-pressure-traction being shown. 

G. Scalp incision enlarged; also a small opening in the underlying temporal fascia 
permitting the temporal muscle to protrude. Note the excellent hemostasis obtained. 

H, I, and J. Applying the small curved hemostats to the subcutaneous fascia for 
the compression of the scalp vessels ; the turning-back of the hemostats affords excellent 
hemostasis upon the removal of the manual pressure. 



PLATE I 











p 








v 


A 




i2 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



OPENING THE BONE THROUGH THE TEMPORAL FASCIA AND MUSCLE 

A. Continuing to apply the small curved hemostats to the subcutaneous fascia for 
the compression of the scalp vessels until no bleeding occurs upon the removal of the 
manual pressure. 

B. Incising the temporal fascia from the zygoma vertically upwards to its attach- 
ment to the parietal crest — but not beyond. 

C. Separating the fibres longitudinally of the underlying temporal muscle and 
exposing the underlying bone. * 

D. Inserting the two lateral retractors of the temporal muscle and fascia in order 
to expose the largest area possible of the underlying bone. (Care must be used not 
to sever the attachment of the temporal fascia and muscle to the parietal crest and 
thus weaken the closure. ) 

E. and F. The sharp periosteal elevator being used the remove the so-called perios- 
teum overlying the bone. A small portion of the line of fracture can be seen. 

G. The Doyen perforator with its pointed tip to be used to make a conical opening 
of the bone down to the dura. 

H. Using the Doyen perforator to make the bony opening at the lower angle of 
the incision — the thinnest portion of the squamous bone. 

/. The Doyen burr to be used to enlarge the bony opening for the insertion of 
the small rongeurs. 

J. Using the Doyen burr which enlarges the outer portion of the perforator open- 
ing only and does not penetrate deeper. 



PLATE II 




i26 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



RONGEUKING THE BONY OPENING 

A. The small pin-point opening of the bone exposing the underlying dura; the 
middle meningeal artery can thus be easily avoided. The irregular line of fracture 
is clearly seen. 

B, and C. The small pointed rongeurs being used first to enlarge the bony open- 
ing downwards and backwards ( away from the middle meningeal artery ) . 

D. The larger rongeurs with the lower blade thinned and bevelled so that it can 
be inserted safely between the bone and the underlying dura. 

E. Using the larger rongeurs to enlarge the bony opening as widely as possible 
beneath the temporal muscle. 

F. The dural separator to be used in severing adhesions between the dura and the 
overlying bone so that the dura will not be torn by the rongeurs. 

G. Using the dural separator to insert a small gauze tape between the dura and the 
overlying bone and thus compressing a bleeding dural vessel. 

H. Another view of the larger rongeurs showing the thinned and bevelled 
lower blade. 

I. Enlarging the bony opening downwards and backwards by the larger rongeurs. 

J. A view of the bony opening at this stage of the operation; a small extradural 
blood-clot can be seen protruding downward from under the upper edge of the bone. 



PLATE III 




H 



i28 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



ENLARGING THE BONY OPENING; THE USE OF BONE-WAX 

A. Continuing to remove the bone as much as is possible beneath the tem- 
poral muscle. 

B. A pellet of sterile bone-wax to be used to stop any bleeding from the diploetic 
vessels by its being rubbed into the bony edge; this wax is an excellent hemostatic. 

C. and D. Rubbing the bone-wax into the bony edges and thus causing all bleed- 
ing to cease. 

E. Continuing to enlarge the bony opening by using the large rongeurs. 

F. A view of the bony opening at this stage of the operation: it is necessary now 
to remove the bone of the upper portion of the operative field. The dura is seen to 
be tense and bulging and therefore under pressure. 

G. Using the large rongeurs to remove the bone along the line of fracture and 
overlying the middle meningeal artery. 

H. Upon removing a bony fragment compressing the meningeal artery, the bleed- 
ing from this torn vessel was profuse, requiring the insertion of two strips of sterile 
gauze between the borie and the artery proximal to the bleeding point. 

2". The torn middle mengineal artery having been successfully compressed by the 
small gauze tape, the rongeurs are again used to enlarge the bony opening. 

J. Another view of a pellet of bone-wax illustrating its soft gummy character. 





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i 3 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



EXPOSURE OF THE DURA 

A. Rubbing the bone-wax into the diploe of the bony edge to control the oozing 
of blood. 

B. Another view of the dural separator. 

C. Using the dural separator to insert a small gauze tape between the dura and 
the bone at the lower angle of the operative field for the control of meningeal bleeding. 

D. and E. Using the dural separator to sever adhesions between the dura and the 
overlying bone so that the danger of tearing the dura with the rongeurs is practically nil. 

F, and G. The large rongeurs enlarging the bony opening as much as possible 
beneath the temporal muscle — to a diameter in adults of almost three inches. 

H. Rongeuring the bone downward as low as possible to the base of the skull, so 
that the drainage of subdural blood and excess cerebrospinal fluid in the middle fossa 
is facilitated. 

/. The tense and slightly bluish dura bulging into the large bony opening; slight 
bleeding from a meningeal vessel being controlled by a small cotton pledget wet in 
warm normal saline solution. 

./. The small dural hook which is used to* elevate the dura when being incised and 
thus preventing any damage to the underlying cerebral cortex. 



PLATE V 











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i 3 2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



OPENING THE DURA 

A. Making a small dural incision by elevating its outer layer with the dural hook 
so that the inner layer of the dura can then be safely and easily opened. 

B. The small dural opening being enlarged by incising the dura upon a grooved 
director bent almost to a right angle: a small amount of subdural blood is seen escaping. 

C. The smootn, flexible spoon-spatula for insertion beneath the dura so that the 
underlying cerebral cortex is not damaged by the dural scissors. 

D. and E. Enlarging the dural opening as widely as possible with the dural scissors — ■ 
the spoon-spatula being inserted beneath the dura. 

F. A small V-shaped silver clip in its grooved holder for the clamping of a 
meningeal vessel before it is severed; in this manner, the dural opening is safely 
enlarged with no loss of blood. 

G. Applying the silver clip to the proximal portion of a meningeal vessel to 
be severed. 

H. After a second silver clip has ligated the meningeal vessel at a point distal 
to the first clip, then the dural scissors sever the vessel between the two clips — and no 
bleeding occurs; the spoon-spatula protects the underlying cerebral cortex from all 
possible damage. 

/. Enlarging the dural opening upward by means of the dural scissors and 
the spoon-spatula. 

J. The tense bulging cerebral cortex tending to protrude through the dural opening; 
a large quantity of supracortical hemorrhage and excess cerebrospinal fluid is escaping 
so that slight cerebral pulsation is now visible. 



PLATE VI 




i 3 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



CLOSURE OF OPERATIVE INCISION 

A. Applying a silver clip to a troublesome bleeding vessel in the lower angle of 
the dural opening. Closure of the incision should not be started until all bleeding 
vessels have been controlled and a small drain of rubber tissue inserted intradurally 
at the lower angle of the incision into the middle fossa beneath the temporo-sphen- 
oidal lobe. 

B, and G. The split temporal muscle being sutured together in one layer over the 
cerebral cortex by continuous catgut (No. 2) ; another drain of rubber tissue is 
inserted intradurally at the upper angle of the incision. The dura is naturally 
not sutured. 

D, and E. The temporal fascia being sutured by interrupted catgut (No. 2) alter- 
nating with interrupted sutures of fine black silk (waxed). 

F. The subcutaneous fascia being sutured by interrupted catgut (No. 1) : as these 
sutures are tied, the adjacent hemostats can be removed with little or no bleeding 
from the compressed vessels of the scalp. (The operative towels and sheets are 
observed to be only slightly soiled by blood.) 

G, and 77. Inserting and tying, respectively, the interrupted fine black silk sutures 
(waxed) of the scalp itself. 

I. Approximating closely the upper layers of the epithelium of the scalp with 
interrupted fine black sutures of waxed silk. 

J. The scalp incision closed and the towels and head drapery removed; a drain 
of rubber tissue is seen extending from both the lower and the upper angle of the incision. 



PLATE VII 



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136 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



THE DRESSING AND HEAD BANDAGE 

A. After the scalp incision lias been gently sponged with a sterile gauze moistened 
in alcohol, a dry sterile gauze pad is placed over the operative area. Another small 
sterile gauze pad smeared with sterile vaseline is inserted behind the lobe of the ear 
to prevent its painful compression by the head bandage. 

B. A sterile roller gauze bandage being applied about the head and under the 
chin; the opposite ear is not covered. Two fingers inserted beneath the chin prevent 
the head bandage from being too snugly applied as to interfere with respiration. 

C. Several strips of adhesive plaster used to "anchor" the gauze bandage so that 
it is held firmly in position. The uncovered ear of the opposite side of the head is 
visible; also the laryngeal tube which facilitated the administration of ether in this 
patient and lessened the cyanosis. 



OPERATION OF CRANIAL DECOMPRESSION 137 

PLATE VIII 




PART II 

ACUTE AND CHRONIC BRAIN INJURIES 
IN ADULTS. ILLUSTRATIVE CASES 



CHAPTER X 

Acute Brain Injuries 

The case-histories reported in this chapter are from a series of patients 
having acute brain injuries; all of the patients have been classified accord- 
ing to the diagnosis, pathology, treatment, and their present condition; if 
death occurred, then the autopsy findings. Each patient has been traced in 
detail from the time of the cranial injury until the present time and the 
present condition of recovery, both of life and of the patient \s former good 
health, has been recorded; the "bad" results are detailed as well as the 
"good" ones, and a critical attitude of the treatment of each patient is 
maintained. The autopsy findings have been most instructive ; the mistakes 
of diagnosis and treatment thus ascertained tend to prevent their repetition. 
— at least, their frequent repetition. 

Under this heading are included not only those patients in whom a 
definite change of cerebral tissue has occurred as the result of a recent 
cranial injury and due to cerebral lacerations, hemorrhage or edema, but 
also those acute cases of cranial injury which, by their clinical history and 
confirmed by repeated neurological examinations, can be classified as simple 
concussion, severe concussion and concussion complicated by various factors : 
post-traumatic neuroses ; cranial injuries producing a doubtful fracture of 
the skuQ; various types of fractures of the vault; then finally that large 
group of patients in whom a definite intracranial lesion has occurred follow- 
ing the cranial injury with and without a fracture of the skull; autopsies 
were performed upon those patients who were unable to recover from their 
injuries. Naturally, the patients in whom there was no intracranial lesion 
of hemorrhage and edema sufficient to increase the intracranial pressure to 
a degree dangerous to life and to future normality, these patients were not 
operated upon — almost two-thirds of the patients, whereas if the intra- 
cranial pressure increased beyond a degree commensurate with life and 
future good health, these patients were operated upon — about one-third of 
the patients (31 per cent.) ; the patients having depressed fractures of the 
vault were all operated upon and the depressed area of bone either elevated 
or, more frequently, removed. 

At the end of each case, certain points of interest regarding the diag- 
nosis and treatment are discussed; where mistakes have occurred, either 
through carelessness or ignorance, an effort has been made to recognize them, 
while mistakes of judgment are pointed out in the hope that a similar error 
will in the future be avoided ; the condition of the patients years after the 
injury, the operative findings, and especially the autopsy findings with ami 
without a preceding operation should and do impress one with the falli- 
bility of our present knowledge of intracranial lesions and their treatment. 
and particularly is this true of brain injuries; it should and does stimulate 
us to exert every effort to ascertain the actual intracranial condition by 
every method uoav known in order that the appropriate treatment be 
instituted early. 



• 



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142 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Cerebral Concussion 

If the term "concussion" is limited to the result of those cranial injuries 
in which merely a sudden jarring of the intracranial contents — the old 
J "commotio cerebri" — produced a temporary functional impairment of the 
I brain and naturally without any ascertainable change of tissue, then the 
\jise of the term ' ' cerebral concussion ' ' is probably correct clinically J The 
condition- itself , however, of simple cerebral concussion, as above restricted 
in its application, is of comparatively infrequent occurrence in hospital prac- 
tice, ,i Jthough.it .is a term most freely used and carelessly applied': the more 
modern methods of examination, and especially the~use of the lumbar punc- 
ture, have made it possible to ascertain more accurately the true intracranial 
condition in these patients, and it is surprising how frequently latent brain 
injuries masquerade under this term. A definite increase of the intracranial 
pressure as recorded by the ophthalmoscope and the spinal mercurial 
manometer and indicating an edematous condition of the brain, and surely 
the presence of blood in the cerebrospinal fluid, point to a condition of 
greater severity than a simple concussion. 

( Possibly the "knockout" in a boxing contest is the best example of a 
simple and true condition of cerebral concussion ;>jthat is, the defeated boxer 
receives a blow from his opponent's fist upon the lower jaw — the force of 
the blow being transmitted upward, either by the ramus on the same side as 
the point of contact and occurring in an "upper-cut" or by the ramus of the 
opposite side of the jaw and following a "swing"; an "upper-cut" deliv- 
ered directly upon the point of the jaw and in the mid-line may have its 
force transmitted to the skull and the intracranial contents by both rami 
^ of the jaw ; either or both mandibulo-temporal articulations are usually pain- 
ty ^ ful and tender. (As the result of this sudden "jolt," consciousness is tem- 
iV ^porarily lost — possibly not longer than twenty seconds, and rarely persist- 
ing more than several minutes;) the pupils are slightly enlarged and react to 
V« light sluggishly (and the blood-pressure may be 110 and even lower.^ (Upon 
the return of consciousness, the man quickly recovers from the stupor, com- 
plains of a dull headache which may continue for twelve to thirty -six hours 
and then he is apparently "as well as ever."' It has been very interesting 
to observe, however, in two fighters who have been "knocked out" several 
times that both of them frequently complained later of headache during a 
period of months and each of them was so susceptible to a blow upon the 
chin or even the head itself that a ' ' knockout ' ' easily resulted — in fighting 
parlance, a "tin and glass jaw." Upon more careful examination, each of 
these men had a chronic edematous condition of the brain — the reflexes 
exaggerated but no Babinski, while the nasal margins of both optic disks 
were indistinctly blurred in the presence of enlarged retinal veins, and the 
spinal mercurial manometer registered the slightly increased pressure of 
11 mm. ; no neurotic or psychic factor could be ascertained in either of these 
men ; naturally, any cardio-vascular or nephritic complication had also been 
excluded. It would seem that this post-traumatic cerebral edema lessened 
the resistance of these men to any blow upon the head which aggravated the 
existing "wet" condition of the brain and it was obligatory for them to 
cease their "ring" activities. 



ACUTE BRAIN INJURIES 143 

The diagnosis of concussion may be tentatively made at the time of the 
injury ; it Is confirmed oiTdisproven by the later clinical history and more 
careful examinations. It is of very common occurrence for ambulance 
patients to be admitted to the hospital with the diagnosis of "cerebral 
concussion, '' ' and yet upon later examinations the definite signs of an intra- 
cranial injury are elicited or the condition of the patient rapidly changes 
to a more serious one exhibiting the progressive signs of an increasing intra- 
cranial pressure — even necessitating the cranial operation of subtemporal 
decompression and drainage. A rather uncommon and yet very striking 
clinical picture of an apparent simple cerebral concussion results from an 
increasing extradural hemorrhage from a tear of the middle meningeal 
artery and usually associated with a fracture of the skull, with or without 
bleeding from the adjacent ear, according to whether the line of fracture 
extends into the middle ear with a rupture of the tympanic membrane ; in 
these patients, the loss of consciousness may be only a temporary one, as in a 
simple concussion, and yet later the definite signs of an increasing intra- 
cranial pressure rapidly occur; if the condition is not early relieved by 
the operation, the increasing intracranial pressure may finally render the 
patient stuporous and eventually unconscious — an extreme condition and a 
very dangerous one for fear of medullary complications ; again, any patient 
remaining unconscious for a period of several hours and especially in the 
absence of shock — that patient should be repeatedly examined for signs 
indicating an intracranial condition other than that of simple shock: the 
temperature, pulse, respiration and blood-pressure at frequent intervals — 
every 30 minutes or one hour ; careful and repeated neurological examina- 
tions and the frequent use of the ophthalmoscope and the spinal mercurial 
manometer. An increasing intracranial pressure with and without the 
presence of blood in the cerebrospinal fluid is most suggestive and imme- 
diately withdraws the patient from that large group of comparatively simple 
conditions. The diagnosis of "cerebral concussion" should not be consid- 
ered a satisfactory and final one until all the clinical resources of examina- 
tions have proved it to be the correct one ; in this respect, the attitude of 
the medical profession toward the diagnosis of ' * cerebral concussion ' ' should 
be similar to that toward "neurasthenia" — a diagnosis to be made after all 
other possible conditions have been carefully excluded. 

"Whether the condition of true "cerebral concussion" results from a 
temporary disturbance of the theoretical molecular relationship of the cere- 
bral tissues or to the more probable combination of an immediate circulatory 
upset with a greater or less degree of shock cannot be stated with certainty. 
The most frequent type of cerebral concussion is of very short duration 
and associated with little or no shock, whereas the more prolonged and 
severe conditions of concussion, as observed in hospital practice, are always 
complicated by a definite degree of shock. 

I. Mild Cerebral Concussion 
Case I. — Mild cerebral concussion. Excellent recovery. 
No. 26. — John'. Twenty-seven years. Colored. Single. Porter. U. S. 
Admitted April 22, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wveth. 



i44 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Discharged April 23, 1914 — 2 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was "beaten up" in a fight in the new sub- 
way; taken to the police station, where he remained all night in a semi- 
conscious condition ; brought to the hospital this morning at 7 o 'clock. 

Examination upon admission (7 hours after injury). — Temperature, 
98.6° ; pulse, 92 ; respiration, 24 ; blood-pressure, 128. Mild degree of shock. 
Semi-conscious. Bleeding from right ear; otoscopic examination revealed 
abrasion of the anterior wall of the external auditory canal ; tympanic mem- 
brane normal. Tenderness just anterior to right ear and posterior portion of 
zygoma. Contusion of upper lip. Contusion of left thigh. Pupils equal 
and of normal reaction. Reflexes, present and equal ; no ankle clonus nor 
Babinski ; abdominal reflexes present and equal. Fundi negative. Lumbar 
puncture — cerebrospinal fluid clear and under normal pressure (approxi- 
mately 8 mm.). 

Treatment. — Expectant palliative treatment of quiet, external warmth 
to body, soapsuds enema and ice-helmet. 

Examination (5 hours after admission). — Temperature, 99°; pulse, 86; 
respiration, 22; blood-pressure, 144. Patient sleeping quietly; easily 
aroused. Mentally confused ; complains of occipital headache ; otherwise 
negative. No bleeding from ear. Reflexes negative. Fundi negative. 
Liquid diet. 

Examination at discharge (one day after admission). — Temperature, 
98.6°; pulse, 84; respiration, 20; blood-pressure, 140. Patient refuses to 
remain in the hospital longer. Slight general headache; emotionally irri- 
table. Mentality clear. Reflexes negative. Fundi negative. 

Examination (October 26, 1915 — 18 months after injury). — No com- 
plaints. Physical examination negative. 

Examination (July 10, 1918 — 51 months after injury). — No complaints. 
Physical condition negative. 

Remarks. — It is surprising how quickly patients recover from the con- 
dition of simple cerebral concussion uncomplicated by shock of any severity ; 
it is not unusual for these patients immediately following an injury to 
appear to be most seriously injured — a question of life itself, and yet within 
18 to 24 hours later the condition has so improved that the patient may be 
considered to be out of danger. As most head injuries, however, are asso- 
ciated with a greater or less degree of shock, then the recovery is not so 
rapid ; if the shock is extreme, a marked improvement may be delayed for 
several days; naturally the treatment in these latter patients should be 
directed toward the condition of shock, and as it improves, then the signs 
of mild or severe cerebral concussion will appear ; it is not at all unusual 
after the shock has subsided to ascertain in the patients having a severe 
condition of concussion, mild signs of an increased intracranial pressure — but 
of only short duration and rarely lasting longer than 12 hours. 

It would seem that in many of these patients having cerebral concussion 
that a mild edematous condition of the brain occurred for several hours fol- 
lowing the cranial injury and that this mildly "wet" condition does not 



ACUTE BRAIN INJURIES 145 

last longer owing* to the excellent vascular reaction that occurs, particularly 
in youthful adults ; the older the patient is above 40 years of age, the less 
rapid and the less able is the patient to react to this condition and naturally 
the convalescence is lengthened. It is v ery d ifficult to differentiate at times 
the conditions of simple, severe cerebral concussion from traumatic cerebral 
conditions of greater severity and frequently the condition must be observed 
over a period of days and even weeks before the diagnosis of simple cerebral 
concussion can be made with certainty ; if the condition persists longer than 
four days to one week following the injury, then the diagnosis must be very 
guarded in that the intracranial condition may be one of more than merely 
simple cerebral concussion; if there is any doubt at all, the most accurate 
examinations and tests should be repeatedly used in order to avoid if possible 
future complications. 

The mild degree of shock present in this patient upon admission must 
have been of greater severity during the preceding seven hours while lying 
in the station-house ; and yet within five hours after admission to the hos- 
pital and merely with the routine expectant palliative treatment of quiet, 
external warmth and ice-helmet, the condition of the patient so improves that 
his blood-pressure has risen from 128 to 144 and the pulse and respiration 
have both begun to descend slightly — favorable prognostic signs. 

The value of otoscopic examinations in the presence of merely blood 
escaping from the external auditory canal is illustrated in this patient ; with 
the improved electrical otoscopes and a sterilization of the otoscopic specu- 
lum, the danger of introducing infection into the inner portion of the 
external auditory canal is very slight indeed, and it is not nceessary to 
insert the speculum farther than just within the external auditory meatus. 
If it had been ascertained at this examination that the tympanic membrane 
itself had been ruptured, then the patient would have been "watched"' 
even more carefully for fear that a more serious intracranial lesion would 
develop — now that it was known that the base of the skull had been frac- 
tured; and there would also be the increased danger, although slight, of 
infection entering through the middle ear. However, it having been ascer- 
tained that the discharge of blood from the right auditory canal was due 
merely to an abrasion of the canal wall itself, and in the absence of marked 
signs of increased intracranial pressure, the prognosis could be considered 
good and the expectant palliative treatment advised with assurance. 

II. Severe Cerebral Concussion 

Case 2. — Severe cerebral concussion ; fracture of surgical neck of left 
humerus. Excellent recovery. 

No. 77.; — Rose, sixty-eight years. White. Married. Housework. Rus- 
sian Jewess. 

Admitted November 17, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Discharged December 14, 1914 — 27 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — "While crossing the street, patient was struck by an auto- 
10 



146 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

mobile and thrown upon the cement ; brought to hospital in the automobile. 

Examination upon admission (18 minutes after injury). — Tempera- 
ture, 98.2°; pulse, 90; respiration, 30; blood-pressure, 122. Patient was 
conscious but dazed. Severe degree of shock. Slight laceration of left fore- 
head and moderate contusion; marked contusion of left shoulder; definite 
crepitus, false motion and sharp pain in left shoulder upon manipulation 
of left arm. Moderate contusion of left hip. No bleeding from nose, mouth 
or ears; no mastoid ecchymosis. No facial paralysis. Pupils enlarged 
equally and react to light sluggishly. Reflexes depressed but equal; no 
Babinski. Fundi negative. 

Treatment. — Expectant palliative treatment; external warmth. Arm 
not treated until shock of accident had disappeared. 

Examination (8 hours after admission). — Temperature, 98.8°; pulse, 
78 ; respiration, 22 ; blood-pressure, 148. Mentally confused ; complains of 
severe frontal headache and pain in left shoulder. Pupils negative. Re- 
flexes negative. Fundi negative. X-ray (Dr. A. J. Quimby) : "Skull nega- 
tive. Left shoulder revealed a fracture dislocation of surgical neck of 
left humerus." 

Treatment. — Appropriate position of abduction and plaster cast for 
shoulder and arm applied. Back rest and frequent turning from side to 
side for fear of pneumonia. Liquid diet. 

Examination (4 days after admission). — Slight headache and aching 
pain in left shoulder ; otherwise negative. Reflexes negative. Fundi 
negative. 

Examination at discharge (27 days after admission). — Temperature, 
98.4°; pulse, 78; respiration, 22; blood-pressure, 146. No complaints 
except soreness in left shoulder. Pupils negative. Reflexes negative. 
Fundi negative. 

Examination (May 10, 1915 — 5 months after injury). — No complaints 
except those incident to old age. Reflexes and fundi negative. 

Last Examination (April 3, 1918 — 55 months after injury). — No com- 
plaints referable to head injury. Reflexes and fundi negative. Patient 
cannot be found since this examination. 

Remarks. — Youthful adults withstand head injuries, and particularly 
the mild results of them, such as concussion, much better than do patients 
over forty years of age. There is less danger of the mild cerebral edema 
being prolonged in that these youthful patients react much more quickly 
than older ones. If this cranial injury had occurred to many patients over 
middle age and especially if they w T ere addicted to alcohol or if their resist- 
ance had been lowered by any cardio-vascular or carclio-nephritic lesion, then 
the prognosis would undoubtedly have been very grave ; it is rare for these 
latter patients to recover entirely from a severe cranial injury — even though 
the diagnosis is only "concussion," so that they are rarely just as well 
five years after the injury as before the injury. 

Cranial injuries occurring to patients over sixty years of age are always 
serious even if the resulting intracranial condition is diagnosed as simply a 
1 ' concussion ' ' of varying degree ; the danger is not so much one of intra- 
cranial complications as it is of, in the first place, hypostatic pneumonia, 



ACUTE BRAIN INJURIES 147 

cardio-vascular and then cardio-renal disturbances ; if the patient has been at 
all alcoholic, then that factor is of great significance. Obese patients do 
not withstand the effects of cranial injuries nearly so well as people of 
normal weight, and even, it would seem, of under weight. 

III. Cerebral Concussion and Its Most Frequent Complications 

A. Extensive scalp lacerations. 

Case 3. — Cerebral concussion ; extensive laceration of scalp. Pott's frac- 
ture of left ankle. Recovery. 

No. 732. — Kate. Fifty-six years. White. Single. Designer. U. S. 

Admitted November 14, 1916, Polyclinic Hospital. 

Discharged December 22, 1916 — 38 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was hit by an auto- 
mobile and knocked down, receiving an extensive laceration of scalp, bruises 
all over the body and fracture of left ankle. Recovered consciousness in 
the ambulance. 

Examination upon admission (43 minutes after injury). — Tempera- 
ture, 98° ; pulse, 110; respiration, 32; blood-pressure, 118. Patient in con- 
siderable shock; semiconscious. Deep laceration of scalp of 4 inches in 
length over frontal region. Swelling of left ankle painful ; no bleeding from 
ears, nose or mouth ; no mastoid ecchymoses. Pupils equal, but are slightly 
dilated and react sluggishly. Reflexes difficult to obtain; abdominal 
reflexes absent. Fundi negative. 

Treatment. — On account of the degree of shock, a warm wet bichloride 
dressing ( 1-5000 ) applied to laceration of the scalp, and the left ankle ' ' just 
let alone." Expectant palliative treatment of external warmth and quiet. 

Examination (6 hours after admission). — Temperature, 98.8°; pulse, 
88; respiration, 24; blood-pressure, 132. Conscious but rather confused 
mentally. No mastoid ecchymosis. Pupils equal and react normally. Re- 
flexes present and equal. Fundi — slight dilatation of retinal veins but 
no edema of the margins of the optic disks. Lumbar puncture — cerebro- 
spinal fluid clear and under normal pressure (approximately 9 mm.). 
Scalp laceration examined; probe reveals no fracture of the underlying 
bone, wound cleansed with iodine and loosely sutured ; 2 rubber tissue drains 
inserted. X-ray (Doctor A. J. Quimby) — "negative for skull; fracture of 
lower end of left fibula." 

Treatment. — Appropriate position and plaster applied by Doctor RE. 
Brennan. Liquid diet. 

Examination (36 hours after admission). — Temperature, 99.8°; pulse. 
86 ; respiration, 26 ; blood-pressure, 138. Patient complains of severe frontal 
headaches; also pain in left ankle. Reflexes negative. Fundi negative. 
Soft diet. 

Examination f>{ discharge (38 days after injury). — Temperature. 98.8° ; 
pulse, 76 ; respiration, 22 ; blood-pressure, 142. No complaints except for 
stiffness of left ankle and in the lumbo-sacral region. Reflexes negative. 



148 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Fundi negative. Laceration of scalp healed entirely and plaster has been 
removed from the left ankle. 

Examination (April 12, 1917 — 5 months after injury). — Patient com- 
plains of ' ' lightheadedness ' ' at times ; is afraid to walk up or down stairs 
without a cane for fear of falling as the result of dizziness. Reflexes nega- 
tive. Fundi negative. No nystagmus ; no Romberg. 

Last Examination (September 17, 1918 — 22 months after injury). — 
Patient still, complains of spells of dizziness, especially in the morning; 
also a fear of falling, causing her to stagger. Still uses a cane. Pupils equal 
and react normally. No nystagmus. No Romberg. Reflexes present and 
equal. Fundi negative. 

Remarks. — The patient has a lawsuit pending against the owner of the 
automobile ; it will be interesting to note if a disappearanct of these annoying 
symptoms will occur after a satisfactory settlement at the trial ; this occurs 
frequently in this type of conditions which may be classed as post-traumatic 
neuroses ; it may not, however, be influenced by the successful termination 
of the suit, although many patients having this type of complaint following 
cranial injuries are usually entirely relieved after a satisfactory settlement 
legally has occurred — frequently within one week after the case has ended 
in court. 

The long hospital residence of this patient was due to the fracture of the 
left leg and not as a result of the cranial injury ; in some patients it might be 
said that this prolonged residence in the hospital is very beneficial to the 
patients in that it prevents them from returning to an active life too early 
and before the intracranial condition has returned to normal entirely, so 
that, when these patients that have been detained in the hospital on account 
of an injury to an extremity, such as a fracture of a bone, when they do 
finally leave the hospital, there is very little danger of their "overdoing" 
and thus tending to precipitate all kinds of "nervous" disturbances and 
emotional annoyances. 

The importance of having these extensive scalp lacerations heal per 
primam is essential. How this patient escaped having a serious infection of 
the extensive scalp lacerations is very impressive and it emphasizes the 
great value of careful shaving of a wide area about the scalp lacerations, 
and then their cleansing with green soap and water and the use both of a 
weak solution of warm bichloride dressing (1-5000) and then either at the 
same time or later the free use of iodine to cleanse the lacerated tissue. 
Naturally, great care should be taken to ascertain first whether a fracture 
of the underlying bone is present, and if it should be present, then the most 
careful application of the solution of iodine for fear some of it might pene- 
trate intracranially, and if the underlying dura should also be torn then 
the great danger of cortical irritation and the production of convulsive 
seizures. (I have seen this complication occur in the accident room of a 
hospital where iodine was freely used to ' ' swab out ' ' an extensive laceration 
of the scalp ; it was afterward ascertained at operation that the major con- 
vulsion which occurred immediately after the use of iodine, had been due 
to the fact that some of the iodine had reached the cerebral cortex through 
an adjacent underlying fracture of the skull and a torn dura. Fortunately, 



ACUTE BRAIN INJURIES 149 

this patient recovered and apparently no ill-effects from the medicinal 
cortical irritation have been permanent.) 

B. Large hematoma. 

Case 4. — Concussion; extensive hematoma; multiple contusions; dislo- 
cation of both shoulders. Recovery. 

No. 49. — James. Fifty-two years. White. Married. Collector. Ireland. 

Admitted June 20, 1914, Polyclinic Hospital. Referred by Doctor 
Alexander hyle. 

Discharged July 6, 1914 — 16 days after injury. 

Family history negative. 

Personal History. — Ten years ago, patient had yellow fever. 

Present Illness. — Patient fell a distance of one story while sleeping upon 
a fire-escape ; recovered consciousness in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.2°; pulse, 104; respiration, 28; blood-pressure, 138. Well devel- 
oped and nourished ; no alcoholism. Semiconscious and very much confused 
mentally as to time and place ; bleeding only from nose. Posterior dislocation 
of both arms at the shoulder (as confirmed later by X-ray) . Abrasions, con- 
tusions and ecchymoses of back, face, especially right eye, and both ex- 
tremities; sprain of right wrist. Huge hematoma over the occiput; not 
tender. Pupils moderately dilated but react normally. Reflexes — patellar 
active and equal ; no ankle clonus but a suggestive right Babinski ; abdom- 
inal reflexes absent. Fundi negative. No paralyses. No abdominal pain, 
tenderness nor dulness. Urine — not bloody. 

Treatment. — Expectant palliative ; as the shock was not severe both shoul- 
der dislocations were immediately reduced. Firm, warm, wet bichloride 
(1-5000) dressing applied to hematoma of head. 

Examination (10 hours after admission). — Temperature, 101.4°; 
pulse, 80; respiration, 24; blood-pressure, 160. Still semiconscious but 
restless. Vomited over one pint of blood; abdomen apparently negative. 
Hematoma over entire occiput very tense ; X-ray (Doctor A. J. Quimby) did 
not reveal any underlying fracture of the vault and therefore merely a firm 
gauze bandage was applied. Pupils equal and react normally. Reflexes — 
patellar present and equal ; no Babinski ; abdominal reflexes depressed but 
equal. Fundi negative, except for possibly a slight dilatation of the retinal 
veins. Lumbar puncture — cerebrospinal fluid clear and under normal pres- 
sure (approximately 9 mm.). 

Examination (48 hours after admission). — Temperature, 100.8°: pulse, 
78; respiration, 24; blood-pressure, 154. Conscious but still mentally eon- 
fused. Complains of pains "all over" head, shoulders and back. Hema- 
toma possibly not so tense. Reflexes negative. Fundi negative. Soft diet. 

Examination at discharge (10 days after admission). — Temperature, 
98.6° ; pulse, 70 ; respiration, 22 ; blood-pressure, 146. No complaints other 
than a general soreness and stiffness — particularly about both shoulders 
and back. Hematoma over occiput less extensive and not tense. Reflexes 
negative. Fundi negative. 

Last Examination (September 17, 1981—46 months after injury). — 
No complaints. Reflexes negative. Fundi negative. 



iSo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Remarks. — If there had been an underlying fracture at the site of the 
occipital hematoma in this case, it would have been most important to have 
kept the overlying scalp in the best possible condition at least, so that the 
danger of an abrasion and contusion of the scalp becoming infected will be 
lessened as much as possible ; the application of a warm, weak, wet bichloride 
(1-5000) dressing seems to be very effective in keeping abrased and con- 
tused areas of the scalp from becoming infected. Only too frequently a 
hematoma of the scalp becomes infected from the "poor" condition of the 
overlying scalp and then if there is an underlying fracture of the skull, the 
risk of infection extending through the fracture down to the meninges is 
very great indeed; if the dura is intact and a purulent lepto-meningitis 
should not occur, there is still danger of an osteomyelitis developing in the 
bone adjacent to the fracture and its rather frequent complication — an extra- 
dural abscess and only too frequently a later cerebral abscess. Even in the 
absence of an underlying fracture of the vault (as demonstrated by X-ray) 
it is frequently better judgment, if there is any question of the hematoma 
becoming infected, to aspirate it through a "clean" area of the overlying 
scalp, and if necessary, to make a small incision, and thus lessen the dan- 
ger of an infected hematoma allowing the infection to extend by the extra- 
cranial veins, lymphatics, etc., down into the large venous sinuses and to 
the meninges themselves. Only too frequently a purulent meningitis and 
infected sinus thrombosis occur by means of this channel of infection. 

The age of these patients is an important factor in their excellent recov- 
ery; the condition upon admission is frequently such that if they are of 
middle age or over, there will be grave doubts whether a recovery of life is 
possible or not. Unless there is a serious intracranial lesion, such as an 
extensive cerebral laceration or a large intracranial hemorrhage, patients 
under sixteen years will recover as far as life is concerned even when the 
prognosis would seem almost hopeless. That is, the treatment and prognosis 
O' of cranial injuries in children up to sixteen years of age is radically different 
and the outlook always more hopeful than in similar cranial injuries in 
adults and particularly above middle age. 

C. Infected lacerations of the scalp. 

Case 5. — Cerebral concussion ; infection of extensive laceration of scalp ; 
severe cellulitis requiring multiple incisions and drainage. Recovery. 

No. 28. — Charles. Forty-four years. White. Single. Chauffeur. 
Sweden. 

Admitted December 12, 1914, Polyclinic Hospital. Referred by Doctor 
C. R. Hancock. 

Discharged January 22, 1915 — 41 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While walking along the street, patient fell into an 
excavation of 6 feet, striking head against an iron pipe ; unconscious upon 
admission to the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 98.2°; pulse, 110; respiration, 30; blood-pressure, 124. Unconscious 
and in shock. Head dripping blood from a large ragged laceration over 



ACUTE BRAIN INJURIES 151 

right frontal and right parietal areas — 7 inches in length; dirt and hair 
rubbed into the tissues. No bleeding from nose, mouth or ears. No neuro- 
logical examination made at this time. 

Treatment. — Head shaved (unfortunately, rather carelessly), scalp 
laceration cleansed with green soap and then iodine swabbed into it ; 
branches of temporal artery required ligation ; wound loosely sutured and 
5 rubber tissue drains inserted; firm dressing applied. The treatment 
of shock consisted of external warmth, quiet (morphia being ordered for 
any restlessness), and hot rectal saline irrigation. 

Examination (6 hours after admission). — Temperature, 99.8° ; pulse, 94; 
respiration, 22 ; blood-pressure, 128. Condition much better. Conscious 
but drowsy; orientation fair. Pupils equal and react normally. Reflexes 
active but equal; no ankle clonus nor Babinski; abdominal reflexes are 
obtained with difficulty but are apparently equal. Fundi negative. Lum- 
bar puncture — cerebrospinal fluid clear and the pressure was normal (ap- 
proximately 8 mm.) ; cell count was 8 per c.mm. X-ray (Doctor A. J. 
Quimby) — "no fracture of the skull revealed." 

Treatment. — Laceration of the scalp dressed; all bleeding had ceased; 
wound again swabbed with iodine and a firm head bandage applied. 
Liquid diet. 

Examination (48 hours after admission). — Temperature, 100.8°; pulse, 
92 ; respiration, 24 ; blood-pressure, 142. Conscious and complains of severe 
pain at site of laceration, which upon dressing is reddened about the edges, 
indurated and distinctly tender; boggy edema to a distance of two inches 
beyond the lacerated tissue. Drains removed and wound again swabbed 
out with iodine; drains reinserted; large wet bichloride (1-5000) dress- 
ing applied. Pupils equal and react normally. Reflexes negative. 
Fundi negative. 

Treatment. — Nothing but liquids ; force water ; vigorous catharsis. Daily 
dressings. Quiet. 

Examination (4 days after admission). — Temperature, 105.4°; pulse, 
120 ; respiration, 32 ; blood-pressure, 164. Irrational and extremely restless, 
requiring restraint. Laceration discharging thin watery secretion. Labora- 
tory report (Doctor Jeffries) — "streptococci." Edema of entire scalp ex- 
tending forward to both orbits and closing both eyes and also downward 
about ears and backward into the neck. Wound reopened, loosely packed with 
wet alcohol gauze after being swabbed with iodine ; without an anesthetic, 
multiple radiating incisions — 7 in all — made over the parietal and occipital 
regions adjacent to the laceration and numerous rubber tissue drains in- 
serted; incisions not sutured. No frank pus obtained by the incisions but 
much watery edema escaped, lessening the tension of the scalp tissues. 
Lumbar puncture — clear cerebrospinal fluid under normal pressure (ap- 
proximately 8 mm.) ; cell count was 8 cells per c.mm. Reflexes negative. 
Fundi — slight dilatation of retinal veins but no definite edema of the optic 
disk margins. No stiffness of neck ; no Kernig obtained. 

Treatment. — Liquid diet; force water: vigorous catharsis. 

Examination (5 days after admission — 18 hours after incising the 
scalp). — Temperature, 101.8°; pulse, 102; respiration. 26; blood-pressure. 



152 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

144. Patient less irrational and not so restless. Condition better in every 
way. Edema of scalp markedly lessened and both eyes can now be opened. 
No definite rigidity of neck; no Kernig. Reflexes negative. Fundi — dila- 
tation of retinal veins still persists but otherwise negative. 

Treatment continued as above. 

Examination (10 days after admission). — Temperature, 99.2°; pulse, 
84; respiration, 22; blood-pressure, 138. Perfectly rational and no com- 
plaints except for general soreness of head. Multiple incisions still dis- 
charging a thin watery pus but no marked tenderness or redness present. 
Original laceration of scalp beginning to granulate. No edema of scalp and 
eyes can be widely opened. Pupils equal and react normally. Reflexes 
negative. Fundi negative. Soft diet. 

Examination at discharge (41 days after admission). — Temperature, 
98.8° ; pulse, 76 ; respiration, 20 ; blood-pressure, 132. No complaints except 
for a general stiffness and numbness of scalp — undoubtedly due to the 
multiple incisions. The original laceration of scalp is practically healed 
except for a small granulating area at its posterior angle. Reflexes nega- 
tive. Fundi negative. 

Examination (November 23, 1915 — 11 months after injury). — No com- 
plaints except for slight headache at times. Reflexes negative. Fundi 
negative. 

Last Examination (March 5, 1918 — 39 months after injury). — No com- 
plaints. Reflexes negative. Fundi negative. General contracture of scalp 
due to scar tissue of incision. 

Remarks. — This was the most severe condition of infection and cellulitis 
of the scalp that I had ever seen; for a time it seemed that nothing would 
check the rapid progress of the infection, and yet at no time did the patient's 
neck become rigid nor did the cell count of the cerebrospinal fluid increase 
beyond 8 cells per c.mm. It would appear that the extensive multiple inci- 
sions of the scalp had in this case afforded such excellent drainage that the 
infective process was ' ' headed off " ; the application of the continuous head 
bath of warm, weak bichloride (1-5000) dressing was undoubtedly a big 
factor in the excellent result. 

This patient had a very narrow escape; the danger of a resulting 
meningitis or an infected sinus thrombosis was very great indeed. If a 
fracture of the underlying skull had been present, then it is very doubtful 
if a purulent meningitis could have been avoided. In treating infections 
of the scalp of this character and also the more typical form of purulent 
cellulitis, free open drainage is essential, and then next in importance in 
the local treatment is the continuous application of warm, weak, "wet" 
bichloride (1-5000) dressings — in fact, a sort of head bath; if a bichloride 
solution is not thought advisable, then merely warm normal saline solution 
may be used — similar to the warm ' ' soaks ' ' for cellulitis of the arm or leg — 
a continuous warm bath for the part affected. The results obtained by this 
method of treatment have been most encouraging. 

D. Alcoholism. 

Case 6. — Severe cerebral concussion ; alcoholism. Recovery. 

No. 36.— Benjamin. Fifty years. Married. White. Bookbinder. 
Ireland. 



ACUTE BRAIN INJURIES 153 

Admitted June 14, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Discharged June 19, 1914 — 5 days after injury. 

Family history negative. 

Personal history negative, except for alcoholic excesses. 

Present Illness. — Patient was found at bottom of stairway ; said to have 
fallen one flight after drinking heavily ; profound unconsciousness. Brought 
to the hospital in the ambulance. 

Examination upon admission (about one hour after injury). — Tem- 
perature, 98°; pulse, 88; respiration, 16; blood-pressure, 146. Semicon- 
scious — not easily aroused but reacted to ammonia fumes; heavy alcoholic 
breath ; deep stertorous breathing but regular. Bleeding from nose but no 
cerebrospinal fluid observed. Superficial abrasion of right temporal region ; 
marked ecchymosis of right eye; abrasion of right knee and left wrist. 
Pupils slightly enlarged but react to light sluggishly. Reflexes — knee-jerks 
absent; ankle jerks absent, elbow and wrist jerks not elicited; no ankle 
clonus; no Babinski ; abdominal reflexes not obtained. Fundi negative. 
Lumbar puncture — cerebrospinal fluid clear and not under pressure 
(approximately 8 mm.). 

Treatment. — Expectant palliative treatment. 

Examination (7 hours after admission). — Temperature, 99.4°; pulse, 
74; respiration, 20; blood-pressure, 140. Patient is still unconscious. 
Respiration deep but regular. Pupils equal and react normally. Reflexes 
elicited as at preceding examination. Fundi negative. X-ray (Doctor 
A. J. Quimby ) — ' ' negative. ' ? 

Examination (18 hours after admission). — Temperature, 99.2°; pulse r 
78 ; respiration, 22 ; blood-pressure, 148. Patient regaining consciousness ; 
marked disorientation as to time and place. Complains of piercing occipital 
headache and general pains "all over body." Pupils equal and react 
actively. Reflexes — knee-jerks difficult to elicit but equal ; no ankle clonus 
nor Babinski ; abdominal reflexes not obtained. Fundi negative. 

Treatment. — Prophylactic alcoholic treatment ; active catharsis. 

Examination at discharge (5 days after admission). — Temperature r 
98.4° ; pulse, 76 ; respiration, 20 ; blood-pressure, 144. Complains of mild 
headache ; otherwise well. Pupils equal and react normally. Reflexes pres- 
ent and equal. Abdominal reflexes depressed but equal. Fundi negative. 
Patient signed the pledge regarding alcoholic abstention. 

Examination (July 4, 1914 — 20 days after injury). — Patient was seen 
drunk holding to a lamp-post. A superficial examination upon a doorstep 
revealed nothing abnormal except depressed reflexes undoubtedly due to 
the alcohol. 

Examination (October 12, 1914 — 4 months after injury). — No com- 
plaints. Reflexes negative. Fundi negative. 

Last Examination (May 12, 1918). — No complaints. Patient has de- 
teriorated very much from alcohol. Pupils equal but react sluggishly. 
Reflexes present but uniformly depressed. Fundi negative, except for a 
retinal suffusion. Urine contains much albumen and many granular easts. 
Medical treatment advised. 



iS4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Remarks. — This patient has deteriorated so much from alcoholism since 
the former injury that it is very doubtful if he could withstand successfully 
the effects of a similar injury now; delirium tremens would occur in all 
probability, and the patient would be most fortunate if he escaped with 
nis life. Whether the cranial injury with the resulting so-called ' ' concus- 
sion" contributed in any way to the patient's greater susceptibility to 
alcohol and the marked mental and emotional deterioration cannot be stated 
with any degree of accuracy; it would seem, however, that such a cranial 
injury could at least do him no good, and possibly permitted him to deterior- 
ate much more rapidly than ordinarily or if the injury had not occurred. 

The danger of delirium tremens developing in patients of this character 
is very great indeed ; it is naturally not so great when the patient is con- 
fined to bed only for several days, but this factor of alcoholism must always 
be considered in the treatment of patients having head injuries — no matter 
now apparently trivial the injury may appear to be. 

E. Existing mental derangement. 

Case 7. — Severe cerebral concussion occurring in a patient mentally 
■deranged; paranoia. 

No. 708.— Camille. Forty years. White. Single. Playwright. U. S. 

Admitted October 13. 19l6, Polyclinic Hospital. 

Discharged November 26, 1916 — 43 days after injury. 

Family history negative. 

Past History. — One week before the injury, relatives had filled out the 
necessary papers and physicians had advised the patient to be committed to 
an institution for the mentally deranged — the diagnosis being paranoia. 

Present Illness. — While crossing the street, patient was struck by an 
automobile and knocked down; quickly recovered consciousness, and was 
Drought in the ambulance to the hospital in a semiconscious condition. 

Examination upon admission (one hour after injury). — Temperature, 
98.4° ; pulse, 80; respiration, 26; blood-pressure, 138. Extremely irrational 
— almost maniacal — requiring restraint. Insists that she is the original 
vampire and therefore called "Camille." She says that the attendants 
show her no longer the respect due her — "a second Cleopatra." A well- 
nourished woman having a laceration, 2 inches long, over left frontal area 
and bruises over entire body. Pupils equal and react normally. Reflexes — 
knee-jerks exaggerated equally; double ankle clonus, and suggestive right 
Babinski; abdominal reflexes absent. Fundi — slight dilatation of retinal 
veins ; otherwise negative. 

Treatment. — Expectant palliative ; usual treatment of scalp laceration. 

Examination (48 hours after admission). — Temperature, 99.8°; pulse, 
86 ; respiration, 24 ; blood-pressure, 142. No complaints. Patient less noisy 
but disoriented; continues to rave about "Cleopatra" and the "saints." 
Reflexes — active but good; no ankle clonus nor Babinski; abdominal re- 
flexes active and equal. Fundi negative. Lumbar puncture — cerebrospinal 
fluid clear and under normal pressure (approximately 9 mm.). X-ray 
(Doctor W. H. Stewart) — "negative for fracture of the skull." 

Treatment. — Restraint as required. Soft diet. 

Examination (8 days after admission). — Temperature, 98.8° ; pulse, 82; 



ACUTE BRAIN INJURIES 155 

respiration, 24 ; blood-pressure, 140. Patient has been normally quiet dur- 
ing the past 10 days. Pleasant, cheerful and has not mentioned her "im- 
portance" and her "power." Laceration of scalp has healed nicely. Re- 
flexes negative. Fundi negative. 

Examination at discharge (13 days after admission). — Temperature, 
98.8°'; pulse, 78; respiration, 22; blood-pressure, 138. No complaints — 
"always feels fine." Patient has refused to eat all food except liquids, 
saying "it's all poisoned." Other than this, patient apparently normal, 
except for egotistical attitude toward the writing of short stories — "I am 
an unusual novelist — in fact, a second Jane Austen." Reflexes negative. 
Fundi negative. 

Treatment. — Patient was given into the custody of her relatives, who 
removed her to the South for the winter. 

Examination (August 1, 1917 — 10 months after the injury). — Accord- 
ing to the relatives and also the patient she "calmed down" so much after 
the accident that institutional care is unnecessary and it has been possible 
for her to live quietly in the family again ; her responsibilities are negligible. 
Reflexes active but equal ; no ankle clonus nor Babinski. Fundi negative. 

Last Examination (August 10, 1918 — 22 months after injury). — Patient 
is now living in Greenwich Village, New York City, among "artists" — 
conducting a tea shop; is able to earn her living and though "eccentric," 
still she is considered normal for that community. Reflexes negative. 
Fundi negative. 

Remarks. — The rest in the hospital during the 6 weeks following the 
injury and then the vacation of the patient to the South where she was 
removed from cares, worries and emotional stress — these two factors un- 
doubtedly improved the patient's mental condition very much so that she 
was really better one year after the injury than before the injury. The 
subsequent history will be very interesting, although it seems that the head 
injury has only been an incident in this patient's condition. 

F. Pneumonia, senility and decubitus. 

Case 8. — Cerebral concussion; pneumonia, decubitus, and senility. 
Death. Autopsy. 

No. 1006. — Margaret. Sixty-six years. White. Married. Housework. 
Ireland. 

Admitted August 3, 1918, Polyclinic Hospital. 

Died August 23, 1918—20 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was knocked down 
by an automobile ; unconscious. Brought by the car to the hospital. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98° ; pulse, 108 ; respiration, 26 ; blood-pressure, 140. Poorly nour- 
ished; in severe shock. Unconsciousness not so profound but that patient 
could be aroused by supraorbital pressure; quickly relapsed, however, into 
unconsciousness. Cold, clammy skin; breathing irregular. Incontinence of 
both urine and feces. No bleeding from the nose, mouth or cars. Bcchy- 
mosis over left temporal region and left posterior auricular region. Pupils 



156 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

contracted equally and reacted to light normally. Reflexes — negative, except 
for a suggestive left Babinski. Fundi negative. 

Treatment. — Expectant palliative and vigorous shock measures. 

Examination (12 hours after admission). — Temperature, 99° ; pulse, 86; 
respiration, 20; blood-pressure, 146. Patient now semiconscious and very 
restless, requiring morphia and restraint. Pupils equal and react normally. 
Reflexes active and equal. Fundi negative. Lumbar puncture — cerebro- 
spinal fluid clear and under normal pressure (approximately 7 mm.). 
X-ray (Doctor G. W. Welt on) — "no fracture revealed." 

Treatment. — Expectant palliative ; liquid diet. 

Examination (4 days after admission). — Temperature, 99.2° ; pulse, 82; 
respiration, 26; blood-pressure, 152. Patient now conscious but drowsy; 
confused mentally and badly orientated as to time, place and personality 
(relatives, however, state that she has been feeble-minded and childish; 
during the past year she has strayed away from home and was lost 
when the accident occurred). Patient continuously says she is going home 
and must be restrained in bed in order to prevent her from walking into 
the corridors of the hospital. She coughs frequently and auscultation 
reveals many coarse and sibilant rales throughout both lungs, particularly 
their lower halves. Numerous ecchymotic areas have appeared over body so 
that owing to general soreness and tenderness patient cannot be moved 
from side to side without causing her pain. Pupils equal and react 
normally. Reflexes — active but equal ; no ankle clonus nor Babinski present. 
Fundi negative. 

Treatment. — Owing to the great weakness of the patient and her ina- 
bility to do anything herself (even swallowing being a great effort for her), 
great care is taken in feeding her liquids and soft diet ; she is turned fre- 
quently in bed from side to side and a low back rest is used in order to 
lessen the danger of pulmonary complications. 

Examination (10 days after admission). — Temperature, 101.4°; pulse, 
90 ; respiration, 28 ; blood-pressure, 152. Patient conscious but irrational. 
In spite of great care, bed sores have developed on each side of the sacrum 
(apparently air cushions were not sufficient and an air or water mattress 
would have been advisable). Patient had been gotten out of bed in a 
chair on the previous day, but she had to be quickly returned to bed owing 
to her great general weakness. Numerous moist rales throughout both bases 
of lungs. Reflexes negative. Fundi negative. 

Examination (15 days after admission). — Temperature, 103.2; pulse, 
94; respiration, 34; blood-pressure, 134. Patient irrational and extremely 
weak. Dulness over right lower half of chest with a marked diminution of 
respiration over this area ; numerous coarse rales. 

Treatment. — For several days, the treatment has been directed toward 
the chest condition — slight elevation in bed, frequent turning and small 
repeated doses of atropine (grains 1/100 every 2-4 hours). The patient, 
however, is so weakened that she does not react as she should. 

Examination (4 hours before death — 20 days after admission). — Tem- 
perature, 106.4 ; pulse, 138 ; respiration, 44 ; blood-pressure, 110. Patient 



ACUTE BRAIN INJURIES 157 

unconscious ; marked cyanosis with shallow irregular respirations. Dulness 
over both bases and lower halves of lungs. 

Autopsy. — Head : no fracture of skull ascertained ; no intracranial hemor- 
rhage, merely a wet edematous brain not under tension. Chest : double 
hypostatic pneumonia. Abdomen negative. 

Remarks. — At the time of the death of this patient, it was my opinion 
that it could possibly have been avoided if the patient had been "gotten 
out of bed" and into a wheel chair upon about the sixth day after the 
injury; it is so important for elderly patients having cranial injuries 
not to be confined to bed for a period longer than one week, and the longer 
they are confined in bed the greater is the risk of the complication of pneu- 
monia, decubitus and the rapid mental deterioration; this latter compli- 
cation is frequently sufficient in itself to hasten the exitus, and especially 
when associated with one or more bed-sores, as it seems that both the mental 
and physical resistance reaches such a low point that the body-cells simply 
refuse to functionate. 

The autopsy findings of a mild condition of cerebral edema and not under 
tension are almost always found in patients following a prolonged illness 
of this character, and especially if the patient is at all alcoholic. 

I. Doubtful "Fractures of the Skull" 

Cranial injuries of sufficient severity to produce a fracture of the skull 
frequently damage the underlying delicate tissues of the brain and the 
intracranial vessels ; for this reason, these injuries became popularly known 
as ' ' fractures of the skull ' ' rather than the important designation of l ' brain 
injuries" — in fact, these two terms were almost synonymous and used inter- 
changeably. "Within recent years it has been surprising to ascertain that 
"fractures of the skull" often occur without an injury to the underlying 
brain or a marked increase of the intracranial pressure, whereas cranial 
injuries without a fracture of the skull very frequently cause such a severe 
damage to the brain from the resulting increased intracranial pressure of 
hemorrhage or edema that an early death will occur unless this pressure is 
immediately relieved and, unfortunately, at times even with an operation. 
Careful autopsy records of these patients indicate the great frequency of 
death due to cranial injuries in the absence of any fracture of the skull — 
the most common direct cause of the death being a high intracranial pressure 
due to cerebral edema and eventually producing a medullary edema ; the 
initial shock following the cranial injury is also a frequent factor, and then 
the condition of intracranial hemorrhage ; the fracture of the skull, however, 
is comparatively unimportant. 

The following case-histories are selected to illustrate the relative unim- 
portance of the presence or not of a fracture of the skull (naturally, de- 
pressed fractures of the skull are excluded), and yet every modern means 
of examination should be employed in order that a complete clinical picture 
of the condition should be elicited. If there are not present the signs of 
severe shock or of a marked increase of the intracranial pressure, then the 
condition of the patient is in no way aggravated by repeated neurological 
examinations, roentgenograms, the use of the ophthalmoscope and o( the 



158 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

spinal mercurial manometer; but to make these examinations while the 
patient is in a severe condition of initial shock or to delay the operation of 
cranial decompression — even ' ' over-night ' ' — when the intracranial pressure 
is high, merely because an X-ray picture has not been obtained, is a mistake 
of the gravest concern and has been the cause of many deaths. The presence 
or not of a fracture of the skull and its location is of no real importance in 
either the diagnosis of the intracranial condition or in the treatment, and 
the appropriate treatment must never be delayed merely to ascertain its 
presence. If the line of fracture should open into the middle ear and the 
tympanic membrane be ruptured, or into the nasal or pharyngeal cavities, 
naturally the risk of infection and possible meningitis would be greater, 
and yet this is a complication which not only rareh r occurs if aural irrigation 
is avoided and no "meddling" occurs, but the condition itself is usually 
easily elicited by inspection alone — or at most by an otoscopic and rhino- 
scopic examination; a positive rontgenogram would in no way change the 
treatment, unless it disclosed a depressed fracture of the vault and it is for 
this latter reason chiefly that rontgenograms are of importance in all 
patients having cranial injuries. 

Recent Doubtful Fractures of the Skull; No Marked Signs of 
Increased Intracranial Pressure ; No Operation 

Case 9. — Doubtful fracture of the skull ; mild signs of an increased intra- 
cranial pressure ; fracture of right humerus, right ankle and right scapula. 
No operation. Recovery. 

No. 65. — Andrew. Fifty-two years. White. Single. Salesman, Germany. 

Admitted September 2, 1914, Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Discharged September 30, 1914 — 28 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was struck by a trolley-car; unconscious for 
several minutes ; brought to the hospital in the ambulance. - 

Examination upon admission (1 hour after injury). — Temperature, 
98.8°; pulse, 96; respiration, 30; blood-pressure, 146. Rather obese but 
robust. Conscious for short periods but badly oriented; no alcoholism. 
Bleeding slowly from right ear; no cerebrospinal fluid observed; no mas- 
toid ecchymosis at this examination. Hematoma and abrasion of right 
cheek and face ; ecchymosis of both eyes, particularly right ; right shoulder 
swollen and ecchymosed. Pupils moderately dilated, equal, and react 
normally. Reflexes negative, except for a suggestive right Babinski. 
Fundi negative. 

Treatment. — Expectant palliative treatment and for shock. 

Examination (48 hours after admission). — Temperature, 99.8°; pulse, 
84 ; respiration, 22 ; blood-pressure, 140. Conscious ; oriented, but remem- 
bers nothing of the day of the accident. Complains of dull throbbing head- 
ache. Slight weakness of right side of face (peripheral type of facial 
paralysis). Bleeding of right ear has ceased; slight mastoid discoloration 
and slightly tender; otoscopic examination reveals a small laceration of 



ACUTE BRAIN INJURIES 159 

posterior lower quadrant of right tympanic membrane. Pupils equal and 
react normally. Reflexes active but equal; no ankle clonus nor Babinski. 
Fundi : slight dilatation of retinal veins and a hazy edema along the nasal 
margins of the optic disks — right being possibly greater than left. Lumbar 
puncture: cerebrospinal fluid straw-colored (laboratory reports "numerous 
red blood-corpuscles") ; under a pressure of approximately 12 mm. X-ray 
(Doctor A. J. Quimby) — "no fracture of skull revealed; fracture of the 
greater tuberosity of the right humerus and a transverse fracture of the 
right scapula; fracture of the internal malleolus of the right ankle." 

Treatment. — Expectant palliative; appropriate splints applied to the 
right shoulder and right ankle. 

Examination (10 days after admission). — Temperature, 102.2°; pulse, 
86; respiration, 24; blood-pressure, 142. Complains of throbbing pain in 
right cheek at the site of the hematoma, which has become "hot and tender. ' r 
(Hot, wet, gauze dressing of normal saline continuously used and the 
hematoma did not break down into frank pus; after 24 hours, its size 
lessened as well as "the pain and tenderness.") Reflexes active but equaL 
Fundi negative. 

Examination at discharge (28 days after admission). — Temperature, 
99°; pulse, 78; respiration, 24; blood-pressure, 144. No complaints except 
for limitation of movement and soreness of right shoulder and right ankle ; 
occasional ' ' light-headed ' ' spells. No weakness of right side of face elicited 
by the special tests. Reflexes negative. Fundi negative. 

Examination (May 12, 1915 — 8 months after injury). — Complains of 
headache, particularly in the morning just after awakening, and of periods 
of dizziness if he should stoop suddenly ; also being easily fatigued — becomes 
tired in the middle of the day when he has his afternoon's work ahead of 
him. (These complaints, however, all disappeared within a month after 
the satisfactory settlement of his suit against the traction company. ) 
Reflexes active but equal ; no ankle clonus nor Babinski. Fundi negative. 

Examination (March 26, 1917 — 31 months after injury). — No complaints 
whatever ; rather euphoric — alcoholism. Reflexes negative although active. 
Fundi negative. 

Last Examination (September 17, 1918 — 48 months after admission). — 
No complaints; "feels fine." Alcoholism has become more pronounced. 
Reflexes active but equal ; no Babinski. Fundi negative. 

Remarks. — The mere fact of blood escaping from the right auditory 
canal might easily have been considered as undoubtedly due to a fracture 
of the base of the skull extending through the right ear, and yet if no 
cerebrospinal fluid is observed in the discharge and the otoscopic examina- 
tion does not reveal a laceration of the homolateral tympanic membrane. 
and the X-ray is negative, then it cannot be stated with certainty that there 
is present a fracture of the skull. In this patient, however, although there 
was only blood observed in the discharge from the ear, and the X-ray was 
negative (as they usually are in fractures of the base alone), the otoscopic 
examination did reveal a laceration of the posterior portion of the right 
tympanic membrane, and it is rare for this complication to occur unless 
the adjacent bone has been fractured 5 it is possible, however, for a small 



i6o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

object to have torn the membrane by penetrating the external auditory 
canal and yet there are usually signs of this external injury in the auditory 
canal itself, and it is a very rare occurrence. It is my opinion that this 
patient did have a fracture of the base of the skull in the region of the 
petrous portion of the right temporal bone and yet it is impossible to 
demonstrate it clinically — other than the fact that the right tympanic 
membrane has been ruptured. 

The mild signs of an increased intracranial pressure, as revealed by the 
ophthalmoscope and at lumbar puncture, were not of sufficient degree to 
warrant the operation of cranial decompression, and these are the patients 
who make excellent recoveries with the expectant palliative treatment alone 
by the natural absorption of the small amount of intracranial hemorrhage 
(if present) and the resulting mild cerebral edema. In this patient, how- 
ever, the absorption of the cerebral edema has been complicated and possibly 
delayed by the factor of alcoholism; whether this increased indulgence of 
alcohol is due to an emotional instability resulting from the cranial injury 
or is a natural sequence of his former life and habits, cannot be asserted with 
any degree of accuracy ; the cranial injury, however, surely could not have 
been of benefit to either his mental or emotional status. 

If the hematoma of the right side of the face had become infected to the 
point of pus formation and if there was a fracture of the base of the skull 
adjacent to the right ear, the danger of this infection extending to the 
meninges through the fracture of the skull would have been very great in- 
deed ; if there is any question of pus formation in the vicinity of the fracture 
of the skull, the hematoma and abscess (if formed) should be incised and 
free drainage afforded in order to avoid any serious complications. 

It is very easy to make the diagnosis of ' ' depressed fracture of the skull ' ' 
when palpation alone is used, especially in the presence of a hematoma or a 
marked edema of the overlying scalp, if the adjacent pericranium has 
been torn, because it gives the sensation of a depressed edge of bone ; ront- 
genograms are most valuable for this differentiation, but if there is still 
doubt then a small exploratory incision of the overlying scalp would be 
advisable — the risk being small, if any, and if there should be a depressed 
fracture of the vault now is the time to know it, so that it can either be 
elevated or removed before definite signs of its presence intracranially are 
exhibited. The weakness of right half of face (peripheral in type), associ- 
ated with a definite impairment of hearing of the right ear (a lesion of 
the middle ear), and with an ecchymosis of the right mastoid area, would 
indicate a lesion of the facial nerve in its bony aqueduct about the middle 
ear — either a fracture of the adjacent bone or merely a temporary edema of 
the nerve itself within its bony canal and thus producing a temporary com- 
pression paresis of the ipsolateral right half of the face. The right tympanic 
membrane being intact and of normal appearance would tend to exclude a 
fracture of the adjacent bones and yet the impairment of hearing, being 
referable to the middle ear, would point to a possible fracture in the petrous 
portion of the right temporal bone. 

Case 10. — Doubtful fracture of the skull ; no signs of an increased intra- 
cranial pressure. No operation. Recovery. 



ACUTE BRAIN INJURIES 161 

No. 87. — Lilly. Forty-eight years. Colored. Married. Housework. U. S. 

Admitted February 28, 1915, Polyclinic Hospital. 

Discharged March 23, 1915 — 27 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Three days before admission, patient was struck by a 
large piece of ceiling falling upon the back of her head and neck ; says she 
was unconscious about 15 minutes and was aroused by friends. Had severe 
headache and pain in neck and back during next 2 days; was sent in a 
cab to the hospital. 

Examination upon admission (10 hours after injury). — Temperature, 
99.4° ; pulse, 84; respiration, 24; blood-pressure, 168. Well developed and 
well nourished negress ; heart and abdomen negative. Few fine moist rales 
over apices of both lungs. Conscious but drowsy. Complains of severe occipi- 
tal headache and dizziness; pain in her eyes and throughout her neck and 
back ; slight stiffness of neck. Slight contusion over occiput but no other ex- 
ternal local marks of injury ascertained. Some clotted blood in left auditory 
meatus ; definite ecchymosis behind left ear over mastoid. Reflexes active, 
the right knee-jerks being possibly greater than the left ; no Babinski. Pupils 
equal and react normally. Fundi negative. Lumbar puncture — cerebro- 
spinal fluid clear and under normal pressure (approximately 9 mm.) . X-ray 
(Doctor A. J. Quimby) — "negative." 

Treatment. — Expectant palliative. 

Examination (6 days after admission). — Temperature, 101.2° ; pulse, 86; 
respiration, 22 ; blood-pressure, 156. Conscious ; still complains of soreness 
"all over" and particularly at back of head. No real rigidity of neck; 
no Kernig. Otoscopic examination reveals small laceration of the left tym- 
panic membrane — in its lower posterior quadrant. Left mastoid ecchymosis 
more marked ; some tenderness upon deep palpation. Pupils equal and react 
normally. Reflexes — knee-jerks sluggish but equal ; no ankle clonus, Babin- 
ski, Oppenheim, Gordon. Fundi (ophthalmoscopic examination by Doctor 
J. A. Kearney) — "external condition normal; both eyes are moderately 
myopic and pigmented retinse peculiar to negroes. Optic disks — media 
clear ; no dilatation of veins of fundus ; arteries and veins in normal rela- 
tion as to color ; disks slightly pale, edges clearly cut all around. ? ' Lumbar 
puncture attempted but not successful owing to the rolls of fat in the lum- 
bar region ; an infective meningitis was feared. 

Treatment. — Expectant palliative continued. 

Examination (12 days after admission). — Temperature, 99.4°; pulse. 
80; respiration, 24; blood-pressure, 154. Still complains of headache, sore- 
ness "all over" and stiffness of neck. (X-ray of cervical region of spine 
negative.) Left mastoid ecchymosis has disappeared. Reflexes active but 
equal. Fundi negative. No Kernig nor real rigidity. 

Examination at discharge (24 days after admission), — Temperature. 
99°; pulse, 76; respiration, 22; blood-pressure, 156. Much better but still 
complains of headache, dizziness and stiffness of neck. Reflexes negative. 
Fundi negative. 

Examination (January 10, 1916 — 11 months after injury, and just 



i6 2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

before her case was to be tried in court). — Same complaints persist: head- 
ache, ' ' light-headed ' ' spells in the morning and when stooping and inability 
to turn neck on account of pain. Pupils equal and react normally. Re- 
flexes active but equal. Fundi negative. Hearing slightly impaired in 
left ear — Weber's test being positive (bone conduction being better than 
air conduction) and therefore middle ear impairment. 

Last Examination (September 17, 1918 — 42 months after injury and 
following an unsatisfactory case (to her) in court). — "Never just as well 
as before injury." General complaints — nothing of any great severity or 
annoyance, however. Reflexes negative. Fundi negative. 

Remarks. — On account of the inability to perform a second lumbar punc- 
ture on the sixth day after admission and the patient having a rise of 
temperature with pain and stiffness of the neck, this caused a fear that a 
meningitis might be occurring in this patient — possibly through an infection 
of the left middle ear, the left tympanic membrane having been lacerated ; 
fortunately this condition did not occur and the inability to perform the 
lumbar puncture was due undoubtedly to its being difficult technically — the 
patient being rather obese. 

Although the X-ray did not reveal a fracture of the skull in this patient, 
yet the presence of a laceration of the left tympanic membrane is very 
indicative that a fracture of the skull, at least of the left petrous bone, did 
exist ; the necessity for possibly more care and frequent examinations would 
naturally be more strongly emphasized — the physician realizing that the 
cranial injury had been a sufficient force to cause a fracture of the skull 
and thus the possible danger of an intracranial lesion must be remembered ; 
besides the ever-present danger of a purulent meningitis and its compli- 
cations resulting from an infection through the line of fracture, especially 
of the ear, nares and pharynx. 

It is interesting to note that in this patient, too, the complaints of head- 
ache, dizziness and stiffness of the neck, all became much less and practically 
disappeared after the termination of the patient 's lawsuit — even though the 
settlement was not satisfactory to her ; the mere relief, both mental and 
emotional that "the case is now over and I am glad of it" was sufficient 
to cause an almost immediate improvement in this patient's condition. I 
believe that a large percentage of post-traumatic neuroses are based upon 
the question of a satisfactory lawsuit or not and that when a satisfactory 
settlement has occurred, these patients improve remarkably quickly. 

An otoscopic examination should be made a routine procedure upon all 
patients having cranial injuries ; in this manner, it can be accurately ascer- 
tained whether a bloody discharge from either auditory canal is due simply 
to an abrasion of the canal wall itself or whether there is a laceration of 
the tympanic membrane, due usually in cranial injuries to a fracture extend- 
ing through the petrous portion of the temporal bone; naturally the dis- 
charge of cerebrospinal fluid from the external auditory canal presupposes 
the presence of a fracture of the skull opening into the middle ear and a 
rupture of its tympanic membrane. It occasionally happens that bleeding 
occurs in the middle ear following a cranial injury and yet the tympanic 
membrane is not ruptured, and therefore the otoscope reveals a tense bluish 



ACUTE BRAIN INJURIES 163 

tympanic membrane ; in some patients it is advisable to perform a paracen- 
tesis and thus permit the blood in the middle ear to escape in the hope that the 
hearing will not be impaired so much as if this clotted blood should be 
permitted to become organized about the tympanic ossicles. Very fre- 
quently in these patients, the impairment of hearing does not persist longer 
than several months, and it has been very interesting to observe a gradual 
increase of the auditory acuity and the change of bone conduction from being 
greater than air conduction to that of air conduction being greater than 
bone conduction. 

Case 11. — Doubtful fracture of the skull; mild signs of an increased 
intracranial pressure ; fracture of the femur. No operation ; repeated lum- 
bar punctures. Recovery. 

No. 248. — Harry. Twenty-eight years. White. Married. Painter. Poland. 

Admitted May 3, 1915, Polyclinic Hospital. 

Discharged June 7, 1915 — 29 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While painting patient is said to have fallen from a 
height of 7 stories; profound unconsciousness. Brought to the hospital 
in the ambulance. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 97.6° : pulse, 142 : respiration, 46 ; blood-pressure, 96. Extreme shock 
made it obligatory to avoid tiring examinations. While the vigorous treat- 
ment of shock was being instituted, inspection revealed ecchymoses of both 
orbits and a large hematoma over right frontal area which upon palpation 
was very suggestive of a depression of the underlying bone. Bleeding from 
nose and mouth but not from the ears; no cerebrospinal fluid observed. 
Complete fracture of lower third of right femur, for which a temporary 
box splint was used. Pupils widely dilated and reacted poorly to electric 
light. Reflexes not examined. Fundi negative. 

Treatment. — Most active treatment for shock: external warmth, hot 
rectal black coffee and saline enemata; lowering of head and shoulders. 
(The cranial condition was not considered in detail and it should not be 
permitted to interfere or delay the treatment of the shock, which demands 
the immediate and the entire attention as being all-important.) 

Examination (6 hours after admission). — Temperature, 98° ; pulse, 126; 
respiration, 34; blood-pressure, 110. Patient is responding to the shock 
treatment — body becoming warmer, pulse stronger and more regular ; un- 
consciousness is not so profound and patient moves his arms at intervals. 
Both eyes are closed by edema and very " black and blue." Pupils could 
not be examined, nor the fundi. 

Treatment. — Expectant palliative. 

Examination (24 hours after admission). — Temperature, 100.2°: pulse. 
108 ; respiration, 28 ; blood-pressure, 126. Conscious at intervals but men- 
tally irrational most of the time ; very restless, requiring restraint. Hema- 
toma of right frontal area very tense and giving the distinct impression. 
upon careful palpation, of a depressed fracture of the underlying bone. 
No mastoid ecchymoses. Pupils and fundi could not be examined on account 



i6 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

of the extensive orbital ecchymoses. Reflexes of left leg very sluggish ; no 
ankle clonus nor Babinski ; reflexes of the arms were negative. Lumbar 
puncture — cerebrospinal fluid blood-tinged (laboratory report — "numerous 
red blood-cells") and under normal pressure (approximately 8 mm.). 
X-ray (Doctor A. J. Quimby) — "no fracture revealed (the head being- 
taken at 5 different angles " ) . 

Treatment. — Expectant palliative; Doctor R. E. Brennan applied trac- 
tion-splint to the fractured right femur. 

Examination (6 days after admission). — Temperature, 99.8° ; pulse, 92; 
respiration, 26 ; blood-pressure, 132. Conscious but still irrational and wants 
to go home. Complains of severe general headache and pain in right thigh. 
Hematoma of right frontal area less tense and possibly not so large. Pupils 
equal and react normally. Reflexes — patellar active, left more than right ; 
no ankle clonus nor Babinski. Fundi negative. Lumbar puncture — cerebro- 
spinal fluid straw-colored (laboratory report — "red blood-cells") and under 
a pressure of approximately 12 mm. 

Treatment. — Owing to the constant severe headache and the increased 
pressure of approximately 12 mm. of the cerebrospinal fluid at lumbar 
puncture, it was thought advisable to withdraw 15-20 c.c. of cerebrospinal 
fluid daily in order to lower this mild intracranial pressure and thereby 
lessen the headache; a lumbar puncture was thus performed daily for 4 
days with surprising and almost immediate relief and a marked general 
improvement; the cerebrospinal fluid appeared clear in the last 2 days 
of its withdrawal and the pressure on the fourth day was only approximately 
9 mm. of mercury. 

Examination at discharge (29 days after admission). — Temperature, 
99° ; pulse, 84; respiration, 26; blood-pressure, 136. No cranial complaints. 
Right thigh is still in a cast. No signs of the former hematoma of the scalp. 
Pupils equal and react normally. Reflexes active but equal; no ankle 
clonus nor Babinski. Fundi negative. 

Examination (November 10, 1913—6 months after injury). — No cranial 
complaints except a "throbbing and buzzing" in the head after severe 
physical exertion or while stooping at a height of several stories. Right 
leg in excellent condition; no apparent shortening (rough measurement). 
Reflexes active and equal. Fundi negative. 

Last Examination (July 10, 1918 — 34 months after injury). — No com- 
plaints. Reflexes active and equal. Fundi negative. 

Remarks. — The severity of the shock was so great and extreme in this 
patient that it was very doubtful whether a recovery of life was possible ; 
it is so important in patients of this extreme character to avoid all unneces- 
sary examinations and disturbance of the patient, and that the treat- 
ment should be directed toward overcoming and lessening the condition of 
shock and thus improving the patient's general condition. External warmth 
to the entire body is possibly the most valuable procedure in combatting 
shock while absolute quiet and hot black coffee and saline enemata are also 
of great value; if the patient is at all restless, small repeated doses of 
morphia hypodermically should be administered. 

It was interesting to observe in this patient that during the period of 



ACUTE BRAIN INJURIES 165 

severe initial shock, there were no signs of an increased intracranial pres- 
sure; this is easily explained because in severe shock of this degree the 
pressure of the blood is very much diminished — as low as 96 as in this 
patient, and naturally it is not possible for a marked rise of the intra- 
cranial pressure to occur (unless immediately following the cranial injury a 
large intracranial hemorrhage had resulted from a tear of an unusually 
large cerebral or intracranial blood-vessel — much bleeding occurring before 
the shock had become pronounced). Then as in this patient when the 
blood-pressure increased as the result of the lessening of the shock, it is 
only then that the signs of an increased intracranial pressure begin to 
appear, and as the blood-pressure increases just so much more does the 
intracranial pressure rise until the signs of an increased intracranial pres- 
sure overshadow all the signs of the former condition of shock. In this 
patient, repeated lumbar punctures daily were sufficient to lessen this in- 
creased intracranial pressure and thus to "tide over" the patient until 
the increased pressure of free hemorrhage and cerebral edema could be 
' ' taken care of ' ' and absorbed by natural means ; in this manner the expect- 
ant palliative treatment of brain injuries in selected patients can be very 
much aided by the careful use of repeated lumbar punctures. 

Repeated lumbar punctures in certain selected cases of brain injuries 
having but a mild increase of the intracranial pressure but associated with 
extreme headache, are of distinct and definite value if properly performed ; 
the cerebrospinal fluid should not be allowed to escape rapidly from the 
needle and great care should be used in not removing too much of the fluid 
at any one time for fear of producing medullary disturbances and particu- 
larly a rapid lowering of the pulse- and respiration-rate due to a mild con- 
striction of the medulla in the foramen magnum; with care, however, the 
danger of this complication is practically nil, and especially in those patients 
who have not marked signs of a high increase of intracranial pressure as 
revealed by the ophthalmoscope and especially by means of the spinal mer- 
curial manometer ; in these latter patients it would be distinctly dangerous to 
remove a large amount of cerebrospinal fluid (over 20 c.c), so that repeated 
lumbar punctures should only be used therapeutically in cases where the 
increased intracranial pressure is mild. The most satisfactory cases are 
those having severe headache, and yet the increased intracranial pressure is 
slight; these are the ones in whom an immediate cessation of the headache 
occurs following the withdrawal of 10-20 c.c. of fluid, and the headache 
may remain absent for a period of 12 hours and even longer ; usually, how- 
ever, the headache returns in these patients within a period of 2-1 hours. 

The indication for repeated lumbar punctures would be possibly greater 
in those patients in whom the headache and other symptoms are severe 
and yet the increased intracranial pressure is not high and the cerebrospinal 
fluid is more than merely blood-tinged; in these patients not only would 
there be a lessening (even though temporarily) of the increased intracranial 
pressure, but the lumbar puncture would be a means of withdrawing and 
thus draining a certain amount of free subdural and subarachnoid hemor- 
rhage so that there would be less new tissue formation, adhesions, etc., after 
the absorption, as much as possible, of this free blood had taken place. The 



166 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

patient described above is an excellent illustration of the benefits that can be 
obtained by frequently repeated lumbar punctures, and it seems that in some 
borderline cases, that this method of repeated lumbar punctures niay be the 
means of avoiding a later cranial decompression and drainage ; however, no 
patient having marked signs of increased intracranial pressure and thus re- 
quiring the cranial operation of subtemporal decompression and drainage 
should be permitted to run the great risk of both life and future normality in 
order to attempt the treatment of the condition by merely lumbar punctures 
— a method of treatment for mild cases only, and possibly to be included in 
what is considered the expectant palliative treatment of brain injuries. 

Fractures of the Vault of the Skull 

Fractures of the vault of the skull and limited to the vault alone are 
usually the result of an overlying "direct" local injury in contrast to the 
fractures of the base of the skull resulting from an "indirect" injury; it 
is not common, however, for linear fractures of the vault to remain limited 
to the vault alone unless the point of contact is a small one and of not great 
force: these linear fractures all tend to radiate to the base and into the 
thinner and weaker parts of the skull. The various types of these fractures 
of the vault have been outlined in Fig. 1. 

It is in these fractures of the vault — whether a linear fracture of the 
outer table alone or of both tables of the skull, that the underlying brain 
and intracranial contents frequently escape all damage, either directly or 
indirectly from hemorrhage and cerebral edema, and thus for these patients 
the proper designation would be a "fracture of the skull"; if, however, an 
intracranial lesion has occurred, the presence or not of a fracture of the 
vault (unless it is a depressed one) is of little or no significance, either in 
the diagnosis or in the treatment, unless the line of fracture permits the 
escape of intracranial hemorrhage and excess cerebrospinal fluid into the 
subcutaneous tissues of the scalp, forming extensive hematomata and thereby 
facilitating a method of natural decompression which may be sufficient to 
lower the increased intracranial pressure to such a degree that the cranial 
operation of decompression and drainage will not be necessary; in these 
patients, if the overlying scalp is not lacerated or bady bruised and infected, 
there is little danger of the complication of infection of the underlying 
hematoma and its extension through the line of fracture intracranially, and 
yet the greatest care should be used to keep the scalp in an excellent condition 
of resistance, and then, if the hematoma becomes too tense, it should be 
aspirated and if necessary, even incised, to facilitate the drainage under the 
most rigid asepsis. 

It should be the routine treatment to shave the entire head of all patients 
having a severe injury to the vault of the skull ; many depressed fractures of 
the vault are overlooked by not taking this simple precaution. A careful 
bimanual examination alone may be sufficient ; naturally, rontgenograms are 
of the greatest aid in establishing the presence of many fractures. 

In many of the possible depressed fractures of the vault, the overlying 
scalp is lacerated so that a probe can be gently inserted and a linear frac- 
ture of the outer table or of both tables of the skull can be ascertained; 



ACUTE BRAIN INJURIES 167 

it is, however, a fairly frequent occurrence for the outer table to remain 
intact while the inner table is fractured and depressed inward ; the X-rays 
are here again of the greatest importance. 

In all depressed fractures of the vault, and if the underlying dura is 
intact, it is the safe procedure, for fear of later trouble, to make a small 
trephine opening at the edge of the depressed area of bone and, by means 
of a blunt periosteal or dural elevator, to elevate the depressed fragments, 
if possible, to their original position ; if this attempt is not successful, then 
the depressed area should be rongeured away. Unless the bone is badly 
depressed, the dura usually remains intact, and I do not believe it should 
be opened in these patients unless there are clinical signs of an underlying- 
cerebral lesion — or in the absence of a high intracranial pressure. 

In all cases of direct fractures of the vault, if it is at all questionable 
whether there is a depression of both tables or of the inner table alone 
of the vault, it is advisable to make a small trephine opening at the edge 
of the possible depression and thus ascertain its presence or not ; if a depres- 
sion is present, it can be very easily remedied, and if not present, no damage 
has been done and very little risk has been incurred — other than the usual 
risk of an anesthetic for several minutes. (A local anesthetic of novocaine 
suffices in many adult patients.) 

The danger of epileptiform attacks occurring after depressed fractures 
of the vault is much greater than following fractures of the base, undoubtedly 
due either to small cortical hemorrhages underlying the area of depression 
and their resulting adhesions of "scar tissue," or to the depression itself 
rendering the cortex more "irritable" and hence more liable to "neurone 
explosion." The presence of an increased intracranial pressure in these 
patients is a definite factor in causing a cortical irritability and thus ren- 
dering the patient more susceptible to convulsive seizures. 

In patients having not only a depressed fracture of the vault but also 
marked signs of an increased intracranial pressure with and without a frac- 
ture of the base of the skull, then an ipsolateral subtemporal decompression 
should be first performed, and then through another incision a trephine 
opening made (as described above) to elevate and even remove the depressed 
area of the vault ; by this method, the general intracranial pressure is safely 
relieved by the decompression and also the future harmful effects of the 
depressed area of the Vault are avoided. If the depressed area of bone is 
situated over either the longitudinal sinus or the lateral sinus, then it is 
frequently wiser not to disturb it, but to rely upon a simple subtemporal 
decompression to offset any pressure effects of the depressed area of the 
vault; besides it is most uncommon for epileptiform seizures to occur in the 
absence of an increased intracranial pressure. 

Recent fractures of the vault alone; no sigtis of an increased intracranial 
pressure. No operation. Excellent recovery. 

A. Linear fractures of the vault. 

1. Outer table alone. 

Case 12. — Linear fracture of the outer table of the vault ; laceration 
of the overlying scalp; multiple injuries. No signs of an increased intra- 
cranial pressure. No operation. Excellent recovery. 



=^==«=— — — ^ ^^^^^^^^^^B^B^^i^H^H^i^H^' ^ ms 



168 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

No. 098. — Michael. Forty-one years. White. Married. Car inspector. 
Ireland- 
Admitted December 31, 1913, Polyclinic Hospital. Eeferred by Doctor 
W. S. Bainbridge. 

Discharged January 5, 1914 — 5 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While trying to stop a runaway street car, patient was 
struck by a plank of wood which knocked the back of his head against the 
curbing of pavement ; unconscious for 20 minutes. Brought to the hospital 
in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 101.6° ; pulse, 88 ; respiration, 20 ; blood-pressure (not taken) . Heavily 
built man in mild shock. Lacerated wound over left occipital bone ; gentle 
probing reveals a crack and apparently a depression at its lower angle. 
Contusion of forehead; compound fracture of the nose associated with 
profuse bleeding and vomiting of blood; Colles fracture of left wrist. No 
bleeding from the ears ; no mastoid ecchymoses. Pupils equal and react nor- 
mally. Reflexes negative. Fundi negative. Lumbar puncture not per- 
formed on account of condition of shock. 

Treatment. — Expectant palliative; laceration of scalp shaved widely, 
cleansed and sutured loosely ; 2 drains of rubber tissue inserted. 

Examination (14 hours after admission). — Temperature, 101.2°; pulse, 
90; respiration, 24; blood-pressure (not taken). Patient conscious and in 
good condition. Reflexes negative. Fundi negative. Lumbar puncture — 
clear cerebrospinal fluid under normal pressure (approximately 6 mm.). 
X-ray (Doctor A. J. Quimby) "shows a definite fracture of the left occipital 
bone and of its outer table alone ; no depression. ' ' 

Treatment. — Nasal splint applied, also reduction of Colles fracture 
effected and appropriate splint applied; expectant palliative treatment 
continued. 

Examination at discharge (5 days after admission). — Temperature, 
98°; pulse, 80; respiration, 18; blood-pressure (not taken). Laceration of 
scalp healing nicely — all sutures having been removed to-day. Pupils equal 
and react normalty. Reflexes negative. Fundi negative. 

Examination (May 12, 1914 — 5 months after injury). — No complaints. 
Reflexes negative. Fundi negative. 

Last Examination (July 10, 1918 — 55 months after injury). — No com- 
plaints; patient, however, has become distinctly alcoholic, and this lack of 
emotional control and instability may be the result of his former head 
injury — a possible etiological factor. Reflexes negative. Fundi negative. 

Remarks. — The condition of this patient and his excellent recovery is a 
good illustration of the small importance both in the treatment and in the 
prognosis of patients having cranial injuries with a fracture of the skull — 
and no signs of an increased intracranial pressure ; although this fracture as 
shown by X-ray was in the most dangerous situation in that it was sub- 
tentorially and radiated downward toward the foramen magnum (even 
though it was only of the outer table alone), yet no definite intracranial 



ACUTE BRAIN INJURIES 169 

signs appeared and particularly those of an increased intracranial pressure 
producing locally the signs of a direct medullary compression. The pres- 
ence of a fracture of the vault or of the base in this patient was of no 
importance in the treatment except to emphasize to the physician the 
severity of the head injury and the possibility of an intracranial com- 
plication and thus the patient would receive more careful attention and 
examinations than might be otherwise given. Subtentorial fractures are 
most dangerous fractures of the skull in that intracranial complications 
and especially direct medullary compression are more liable to occur, and 
if severe and an early relief of the compression is not effected, then the 
mortality is very high — undoubtedly higher than in any other form of 
brain injury. 

It is unwise to make prolonged neurological examinations upon these 
patients when in the initial condition of shock ; it is much better judgment 
to wait until the shock has subsided before attempting thorough and tiring 
examinations ; for this reason the lumbar puncture was not performed upon 
this patient, even though he was only in mild shock, for fear the condition 
of shock would at least be prolonged and possibly increased. A blood-pres- 
sure record, however, would have been very interesting in this patient as an 
indication of the severity of the initial shock and its gradual subsidence. 
The condition of shock is such a big factor in the prognosis of these patients, 
and particularly in obese adults over middle age, that its estimation should 
always be recorded and for that purpose naturally, the blood-pressure is a 
most valuable aid. 

In the estimation of shock in these patients upon their admission to the 
hospital immediately after the injury, the temperature, pulse, respiration 
and blood-pressure are excellent indices of the extent and severity of the 
shock then present — this is particularly true as illustrated by the tempera- 
ture, which is subnormal in the vast majority of these patients, and also of the 
blood-pressure, which may be lowered to even a hundred and less in the most 
severe cases, whereas the increased pulse-rate and also respiration-rate are 
valuable aids in determining the severity of the shock ; the general condition 
of the patient — even an abolition of all reflexes, superficial and deep, should 
be considered as well as the state of the peripheral circulation — pale, cold^ 
clammy skin, etc. All efforts in treatment should be directed toward the 
overcoming of the condition of shock, and once the condition of shock 
has subsided, then the true condition, especially intracranially, can be 
estimated and treated accordingly ; very frequently the signs of increased 
intracranial pressure (if a large hemorrhage has occurred intracranially 
before the onset of shock) are overshadowed and submerged by the signs 
of shock occurring a short time later, and frequently the mild signs of shock 
are completely obscured by a high intracranial pressure which is possible 
and which has resulted because the shock was of only mild degree — and 
therefore the blood-pressure was of sufficient height to permit a large 
intracranial hemorrhage to occur as the result of a torn vessel. It is most 
rare, however, for the condition of severe shock to be present and at the same 
time associated with a high degree of increased intracranial pressure: the 



i 7 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

one tends to obliterate and make impossible the other in their extreme 
and severe stages. 

It is most important in patients having linear fractures of the vault, 
either of the outer table alone and particularly if both tables are fractured, 
that if there is an overlying laceration of the scalp, then this scalp wound 
should be widely shaved, thoroughly cleansed with green soap after all for- 
eign particles have been extracted as well as possible by means of forceps, 
especially hair, pieces of stone or dirt, etc., then the tissues swabbed with 
iodine (great care being taken that no iodine is permitted to enter the line of 
fracture for fear of producing a severe irritation of the underlying cerebral 
cortex, especially if the dura has been torn, and thus being the cause of 
convulsive seizures) ; two or more drains of rubber tissue should be inserted 
into the angles of the laceration and then the edges of the wound loosely 
sutured, so that the tissues will be under no marked tension, and if an 
infection should occur, the purulent secretion will easily escape through 
the scalp incision at the points of drainage rather than, being blocked by 
a too close approximation of the edges of the scalp laceration, the great 
danger of the infection penetrating into the intracranial cavity through 
the line of fracture. It is surprising how frequently these "dirty" infected 
lacerations of the scalp, with or without a fracture of the underlying vault, 
heal per prim am with scarcely any redness or edema of the tissues after the 
wound has been cleansed as described above and its edges approximated 
loosely and the drains in situ; careful shaving of the surrounding scalp is 
an essential to "first intention" healing of scalp lacerations. 

Fractures of the vault of the skull can now be easily located and 
accurately portrayed by having a series of rontgenograms made at different 
angles to the vault so that it is possible in this manner to locate small and 
unsuspected linear fractures — either of the outer table alone or more 
commonly, of both tables, with or without depression. It is becoming more 
and more recognized that linear fractures of the vault are of very common 
occurrence following head injuries of apparently trivial severity; these 
latent linear fractures of the vault which would not be diagnosed without the 
aid of the X-ray are of no importance in the treatment, except to impress 
both the physician and the patient with the necessity of more careful exam- 
inations for fear that a definite intracranial lesion, and particularly an 
increased intracranial pressure, may develop within several days of the 
injury; that this patient should be confined to bed even though "feeling 
all right," should be repeatedly examined daily, especially neurologically 
and ophthalmoscopically, and that the patient should not re-enter the 
former active, vigorous life until a period of at least several weeks has 
elapsed. The vast majority of these patients having simple linear fractures 
of the vault do not develop marked signs of increased intracranial pressure 
and therefore they make excellent recoveries with the expectant palliative 
treatment alone. It must always be remembered that the fracture of the skull, 
and particularly the simple linear fractures of the vault and also of the base, 
are possibly of the least importance and the smallest factor in the treatment 
and prognosis of cranial injuries — the most important factor being the pres- 



ACUTE BRAIN INJURIES 



171 



ence or not of high intracranial pressure, whether due to intracranial 
hemorrhage or cerebral edema. 

2. Both tables of the vault. 

Case 13. — Linear fracture of both tables of the vault; no signs of an 
increased intracranial pressure. No operation. Excellent recovery. 

No. 931. — John J. Sixty-one years. White. Married. Boat-builder. 
United States. 

Admitted November 22, 1917, Polyclinic Hospital. Referred by Doctor 

Alexander Lyle. 

Discharged December 16, 1917—24 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness .—While crossing the street, patient was struck by an auto- 
mobile ; unconscious. Brought to the hospital in the automobile. 

Examination upon ad- 
mission (15 minutes after 
injury) . — Temperature, 
98° ; pulse, 86; respiration, 
28 ; blood-pressure, 140. 
Unconscious and in mild de- 
gree of shock. Hematoma 
over left squamo-parietal 
suture. No bleeding from 
nose, mouth or ears. Pupils 
equal and react normally. 
Reflexes obtained with diffi- 
culty, but equal ; no Babin- 
ski ; abdominal reflexes 
could not be elicited. Fundi 
negative. Lumbar punc- 
ture — cerebrospinal fluid 
clear and under normal 
pressure (9 mm.). 

Treatment. — Expectant palliative. 

Examination (14 hours after admission). — Temperature, 99.6°; pulse, 
80 ; respiration, 22 ; blood-pressure, 144. Conscious but confused men- 
tally. Extensive hematoma of left side of the head with an underlying 
definite line of tenderness; hematoma apparently enlarging. Pupils 
negative. Reflexes active but otherwise negative. Fundi negative. 
X-ray (Doctor G. W. Welton) " shows a linear transverse fracture of 
left parietal bone ; also an apparent dislocation of the last 3 coccygeal 
bones" (Fig. 54). 

Treatment.— Expectant palliative ; scalp over hematoma carefully shaved 
and cleansed for fear of infection (apparently an extradural hemorrhage was 
being drained through the underlying fracture of the bone). 

Examination (6 days after admission). — Temperature, 99.2 C ; pulse, 74: 
respiration, 20 ; blood-pressure, 144. Markedly improved : entirely conscious 
and well oriented. Hematoma over left parietal region decreasing in size 




Fig. 54. — Transverse linear fracture of left parietal bone with 
no signs of an increased intracranial pressure; naturally no 
operation. Excellent recovery. 



172 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and becoming less tense. Pupils equal and react normally. Reflexes active 
but otherwise negative. Fundi negative. 

Examination at discharge (24 days after admission). — Temperature, 
98.8° ; pulse, 76 ; respiration, 20 ; blood-pressure, 142. Feels well except for 
pain in the coccyx, which has considerably lessened within the past 3 days. 
Hematoma has entirely disappeared ; a definite line of tenderness, however, 
persists at the site of the fracture, which can be accurately palpated. Re- 
flexes active but otherwise negative. Fundi negative. 

Examination (May 10, 1918 — 5 months after injury). — In excellent 
health and no complaints ; feels possibly better now than before the injury — 
due to the fact that he is taking excellent care of himself, having had 
his first vacation in 14 j^ears. Reflexes active but otherwise negative. 
Fundi negative. 

Last Examination (January 20, 1919 — 14 months after injury). — No 
complaints, and is working as hard as formerly. Reflexes active but other- 
wise negative. Fundi negative. 

Remarks. — The presence of a hematoma over the lower left parietal area 
with a fracture of the underlying bone as revealed by the rontgenogram, and 
the gradual enlargement of this hematoma until it became very tense, would 
point to the hematoma as being the result of blood extruding through the 
fracture of the bone and thus preventing an increase of the intracranial pres- 
sure by its escape — a sort of natural decompression; the absence of blood 
in the cerebrospinal fluid at lumbar puncture would tend to indicate that the 
bleeding was extradural entirely, and yet this cannot be stated with cer- 
tainty because it is frequently ascertained at operation that a subdural 
and subarachnoid hemorrhage in fluid form can be present in fairly large 
amount and yet the cerebrospinal fluid at lumbar puncture is clear — both 
macroscopically and microscopically — up to the time of the cranial opera- 
tion. This observation, however, has only been confirmed in patients having 
a marked increase of the intracranial pressure (as naturally these are the 
only patients operated upon), and whether in these patients having sub- 
dural bleeding and yet no blood in the spinal cerebrospinal fluid there is 
a blockage of the intracranial spinal fluid at the foramen magnum so that 
in some patients the intracranial blood can therefore not descend into the 
spinal canal — this explanation cannot be sta+ed with certainty; in patients, 
however, who have no marked increase of the intracranial pressure and 
also no blood in the spinal cerebrospinal fluid, whether there is free blood 
or not in the intracranial cerebrospinal fluid cannot be demonstrated, but if 
the blockage is due to an increased pressure at the foramen, this factor would 
not be present in these patients. 

It would seem that here again we have at sort of ' ' natural ' ' decompres- 
sion resulting from the intracranial blood being able to escape through the 
line of fracture of the vault and thus forming a hematoma within the over- 
lying scalp ; as no blood was demonstrated to be present in the cerebro- 
spinal fluid at lumbar puncture, it would seem that either the amount of 
intracranial hemorrhage had been small and quickly absorbed, or that so 
much intracranial free blood had escaped through the fracture and had been 
absorbed at the site of the hematoma so that in this manner the signs 



ACUTE BRAIN INJURIES 173 

of a definite increase of an intracranial pressure had been avoided. In cases 
similar to this, the fracture of the vault is to be hoped for, and instead of 
it increasing the severity of the condition and making the prognosis more 
grave, it on the contrary increases the patient's chances of recovery 
without an operation — not only as to an immediate recovery but as to the 
patient's ultimate good health. It is in these patients, however, that if there 
is any question of an infection of the hematoma overlying the fracture of the 
vault, then there should be no hesitancy in at least aspirating the hematoma 
through a "clean" area of the scalp repeatedly, and if necessary a small 
incision made and a drain of rubber tissue inserted — for fear that the 
hematoma might otherwise become infected and its extension through the 
line of fracture intracranially would result in a fatal meningitis or a later 
brain abscess. Any contusion or abrasion of the overlying and adjacent 
scalp should be most carefully cleansed and a wet bichloride ( 1-5000 ) 
dressing or a gauze dressing with a mild solution of alcohol applied. 

3. Linear fracture of both tables of vault of skull associated with high 
intracranial pressure due to large extradural hemorrhage. Incision of 
scalp and drainage. Eecovery. 

Case 14. — Acute severe brain injury associated with a wide linear frac- 
ture of the skull and with signs of high intracranial pressure due to a large 
extradural hemorrhage ; left hemiplegia. Scalp incision and the partial 
removal of the extradural hemorrhagic clot through the fracture of the 
vault. Recovery. 

No. 009. — Yuan. Thirty-five years. Yellow. Married. Eldest son of 
the first President of China. China. 

First Examination (May 12, 1912 — 10 weeks after injury). — Summer 
home of Emperor of China at Yangteh Fu, Honan, China. Referred by 
Captain Tsai Tin Kan. 

Operation (May 22, 1912 — 11 weeks after injury). — Removal of extra- 
dural clot through overlying linear fracture of vault. 

Last examination June 6, 1912, 14 days after operation. 

Family history negative. 

Personal History. — Negative ; always well and strong. 

Present Illness. — Ten weeks ago while riding horseback, patient was 
thrown to the ground, striking the back of his head against a large boulder : 
immediate loss of consciousness; no bleeding from the nose, mouth or ears; 
diffuse boggy hematoma over entire top of head (no signs of it at examina- 
tion now except an indistinct bluish area over the right parietal bone). 
Patient regained consciousness upon the sixth day after the injury and 
it was then learned that there was a complete left hemiplegia. Patient 
complained of severe frontal and occipital headache and dizziness. 

Treatment has been of the expectant palliative type and during the past 
10 weeks the general condition of the patient has steadily improved with the 
exception of the continued complete left hemiplegia. 

Examination (10 weeks after injury). — Temperature, 98.8°; pulse, 66; 
respiration, 18; blood-pressure, 136. Fair development and nourishment. 
Conscious; complains of dull frontal and occipital headache. No aphasia nor 
paraphasia (patient being right-handed, as were his parents and grand- 



i 7 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

parents). Complete left hemiplegia — left side of face being possibly less 
paralyzed than the left arm and left leg, which could not be moved — not 
even a finger or toe of the left hand or left foot. No marked impairment 
of sensation of the left side of the body, except a general dulness of the 
sensation to light touch and pin-pricks; these sensations were all delayed, 
which was considered at the time to be due to a lack of concentration and 
a slight mental retardation of the patient. Owing to difficulty of language, 
no accurate estimation of patient's mental and emotional status could be 
ascertained, although he apparently appeared to be normal — and the Chinese 
doctors considered his mentality "ding how" (excellent). Some impair- 
ment of the stereognostic sense of the left hand — not present in the right 
hand. No apraxia. Definite tenderness over the right parietal area; no 
depression palpable. Pupils — right larger than left and reacts to light 
sluggishly. Reflexes : patellar — left very much exaggerated, patellar clonus 
being elicited; left inexhaustible ankle clonus and left Babinski but only 
right exhaustible ankle clonus and a suggestive right Babinski ; left abdom- 
inal reflex absent, right inactive ; deep reflexes of left arm and left masse- 
teric reflexes markedly increased. Fundi — retinal veins full, tortuous and 
almost buried in edematous retinas about the optic disks ; nasal halves and 
temporal margins blurred by edema but no measurable swelling ascer- 
tained — that is, a papilledema but not to the extent of producing ' ' choked 
disks." Lumbar puncture — clear cerebrospinal fluid under high pressure 
(approximately 20 mm.). No X-ray picture could be taken — there being 
no X-ray machine nearer than Pekin, a distance of 400 miles. 

Treatment. — In the presence of the general signs of such high intra- 
cranial pressure and confirmed by the more accurate ophthalmoscopic and 
lumbar puncture tests, and in the presence of the localizing signs of a left 
hemiplegia, slight sensory impairment and indefinite astereognosis, the 
diagnosis was naturally one of extensive intracranial hemorrhage com- 
pressing the right cerebral hemisphere, and most probably an extradural 
one, especially in the absence of blood in the cerebrospinal fluid at lumbar 
puncture and of the signs of cortical irritation such as convulsive seizures. 
The fact that these pressure and localizing signs had persisted for a period 
of ten weeks following the injury in spite of the expectant palliative 
method of treatment, it was considered most improbable that this intra- 
cranial hemorrhage could be absorbed by natural means; it was, there- 
fore, advised that the patient should be transported to Pekin, where 
a cranial operation could be performed in a hospital under the modern 
conditions of asepsis and assistance. The family, and particularly the 
mother of the patient, would not consider the journey to Pekin so that, after 
a period of 10 days, consent was finally obtained for an incision of the scalp 
overlying the right parietal area, using cocaine anesthesia ; it was thought 
a small trephine opening could be made in this area and, if an extradural 
hemorrhage was present, it could be removed, or at least a large part of it, 
through this small opening — a comparatively simple procedure and devoid 
of danger to the patient. After much discussion, delay and differences of 
opinion (there being nine doctors in consultation), a permission for this 
operation was finally obtained. 



ACUTE BRAIN INJURIES 175 

Operation (11 weeks after injury). — Scalp incision with removal of 
extradural clot through the line of fracture of the overlying vault (cocaine 
anesthesia alone being used) ; patient's head had been carefully shaved and 
cleansed with soap and alcohol ; under cocaine anesthesia a small vertical 
incision of two inches was made over the right parietal area; upon retrac- 
tion, much "free" blood clot was found in the subcutaneous tissues and 
protruding through the pericranium beneath the fronto-occipital aponeu- 
rosis, giving the latter a bluish tint ; upon incising it, therel was exposed a 
fracture of the underlying parietal bone, over one-eighth of an inch in width 
and extending antero-posteriorly about one and a half inches from the 
longitudinal sinus which it paralleled. Protruding through this wide line 
of fracture was a bluish blood-clot of the consistency of soft gelatine, and 
upon removing the outer portion with small forceps the underlying portion 
of blood-clot was forced upward by the increased intracranial pressure and 
thus it was exuded extracranially ; as this clot was removed by the forceps 
from the line of fracture, more blood-clot was forced into view and in this 
simple manner almost 4 tablespoonsful of semi-solid blood-clot were removed ; 
then dark blood of the consistency of currant jelly oozed through the line 
of fracture and over 2 ounces welled out at this time. A small probe now 
inserted through the line of fracture revealed the underlying dura depressed 
about 1 cm. beneath the inner table of the vault of the skull, but apparently 
it was intact. Two small strips of rubber cut from a glove and thoroughly 
boiled were now inserted as drains just through the line of fracture, and 
came out at either end of the scalp incision, which was closed loosely by 
5 silk sutures. "Wet gauze dressings (thoroughly boiled) were now applied 
and a large head bandage. Duration — 40 minutes. 

Post-operative Notes. — The wound continued to drain a large amount 
of dark syrupy blood which finally ceased on the third day after opera- 
tion ; the rubber drains were now removed. Patient had almost immediate 
relief of the severe headache and on the fourth day after operation, he 
found it possible to move the toes of the left foot and the fingers of the left 
hand. The improvement daily progressed so that on the eighth day after 
operation he was able to move both the left arm and the left leg, and on the 
twelfth day after operation he was able to move about with improvised 
crutches ; normal sensation over the left side of the body and there was no 
astereognosis to be elicited in the left hand. Operative incision healed 
per primam. 

Last Examination (14 days after operation). — Temperature, 98.6°: 
pulse, 74 ; respiration, 20 ; blood-pressure, 134. Perfectly conscious ; appar- 
ently no impairment of mentality nor emotional instability. No complaints 
except a feeling of soreness at the site of the scalp incision, which has healed 
perfectly. Only slight weakness of the left arm and left leg can be elicited by 
special tests, and no weakness of the left side of the face ; no sensory impair- 
ment ; no astereognosis. Pupils equal and react normally. Reflexes : patellar 
— exaggerated, left more than right ; only left exhaustible ankle clonus 
and a tendency to left Babinski, but normal right reflexes; abdom- 
inal reflexes depressed, left more than right: deep reflexes of left arm 
greater than right; masseteric reflexes — both sides equal. Fundi — retinal 



176 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Terns enlarged, right possibly more than left; nasal margins only of both 
optic disks blurred by edema, right possibly more than left. Patient is able 
to walk a number of steps without crutches and is regaining very rapidly 
the strength and use of left arm and left leg. 

Treatment. — Daily massage and exercises of left side of body; general 
hygienic measures ; triple bromides, grains x, three times a day, after- meals, 
to lessen the cortical irritability and thus decrease the danger of future 
■convulsive seizures. 

Report (February 28, 1913 — 9 months after operation). — Letter from 
Mr. J. C. Wang, secretary to the President: "Your patient has made an 
■excellent recovery; there is still some weakness of the left leg but his left 
arm. is now well. He is leading a quiet life in their home in Honan ; he is 
planning to come to Pekin this summer. ' ' 

Report (September 16, 1914 — 27 months after operation). — Patient had 
a convulsive seizure, 25 months after the operation, and apparently begin- 
ning 1 in the left leg; no loss of consciousness in the first three! Jacksonian 
convulsions, but he has now had six general convulsive seizures with loss 
of consciousness. "Will an operation upon his head help him now get 
over this disease ? ' ' 

Last Report (49 months after operation). — On the same day that his 
father was found dead under rather suspicious circumstances, this patient — 
the President's eldest son — was also found dead in bed, presumably 
from poison. 

Remarks. — This patient was a most instructive one from many points 
of view: for an increased intracranial pressure of such high degree to 
persist for a period of eleven weeks following the cranial injury and yet 
no marked mental and emotional impairment to result as well as no signs 
of a definite medullary compression and even loss of medullary compensation 
to the degree of a medullary edema, is most unusual ; these patients, having 
.an increased intracranial pressure of such marked degree, unless this pres- 
sure is relieved comparatively early, gradually become exhausted so 
that a sudden onset of medullary edema frequently occurs; the fact that 
this patient was not beyond middle age was of great value to him. 

This is the only patient in this series of brain injuries in whom it was 
possible to relieve the intracranial hemorrhage by means of removing the 
extradural blood-clot through a linear fracture of the vault ; there are many 
patients who "decompress" themselves by the intracranial "free" blood 
escaping through the line of fracture extending through either ear, the nares 
or through a linear fracture of the vault, producing a hematoma of varying 
degree; but it is most rare, I believe, and I cannot find a similar case in 
the literature of brain injuries, where it was possible to remove clotted and 
semi-solid blood through a single line of fracture of the vault — clotted blood 
of the amount sufficient to relieve the intracranial pressure and direct com- 
pression so that the resulting condition of paralysis and other definite 
cerebral impairment was markedly benefited. The reason for this is due 
chiefly to the fact that it is a most rare occurrence for a linear fracture 
of the vault to be so widely dilated that it is possible for clotted blood to be 
extruded by the resulting increased intracranial pressure, and unless the 



ACUTE BRAIN INJURIES 177 

fracture of the vault is a comminuted one, then only the blood in fluid 
form can escape to form the hematoma and the clotted blood is unable to 
escape owing to the linear fracture being usually but a narrow line — not 
wider than a mere crack into which it would be most difficult to pass a sheet 
of the thinnest paper. In this patient, however, the linear fracture undoubt- 
edly resulted from the "bursting" effect of the cranial injury, and, as 
Doctor 0. H. Schultze has frequently demonstrated in this type of fracture 
of the vault, the central portion is more widely dilated than either end, 
and in this particular patient the fracture was separated widely, similar 
to the diastasis of suture lines following cranial injuries. The bogginess 
over the top of the head following the injury in this patient was undoubt- 
edly due to the escape of fluid blood through this line of fracture ; the extra- 
dural hemorrhage being of slow but continuous formation, soon clotted 
so that within 12 to 24 hours following the injury no more extradural blood 
could escape through the line of fracture and thus there was formed this 
large extradural clot lying directly beneath the site of the fracture of the 
vault — possibly the size of a flattened orange, and directly overlying the 
motor area of the right cerebral hemisphere. It is very probable, therefore, 
that the left hemiplegia did not occur until possibly 24 hours after the 
cranial injury when the clotting of the extradural hemorrhage prevented 
its being extruded through the line of fracture and thus the intracranial 
pressure was gradually increased as the dura was slowly dissected, as it 
were, from the inner table of the vault at the site of the fracture until the 
extradural hemorrhage had reached its large size and the bleeding vessel 
or vessels had become thrombosed; as the result of this increasing intra- 
cranial pressure, the patient did not regain consciousness as early as is usual 
for these patients and when he did, then it was noticed for the first time 
that the left side of the body was paralyzed. 

This patient should naturally have had a right subtemporal decompres- 
sion first performed to relieve the increased intracranial pressure, and then 
a removal of an area of bone, preferably a small osteoplastic flap over the 
right parietal area — the site of the extradural hemorrhage. In this manner, 
the increased intracranial pressure could have been entirely removed and 
the extradural clot completely evacuated so that the danger of future 
complications would have been very slight indeed. It being impossible, 
however, to transport this patient to a hospital where such an operation 
could be safely and successfully performed, and it not being possible to 
obtain the consent of the patient's mother for a more extensive operation 
than a mere exploratory incision of the scalp overlying the site of the cere- 
bral lesion, it was therefore obligatory, if anything was to be attempted 
to improve the condition of this patient, that it should be of the most incom- 
plete and superficial character — but as safe as the conditions would warrant. 
The instruments and operative gauze sponges and dressings were all boiled 
for a period of 15 minutes and used wet, and the operator was the only one 
to touch the instruments and the gauze sponges and dressings with his sterile 
gloved hands; the two retractors with long handles were held by two 
Chinese doctors who were not surgically "clean" but known to be "dirty" 
and who were therefore not permitted to touch anything ; in this manner, the 
12 



178 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

danger of infection of the wound was minimized, although the general 
conditions in the room, the patient's bedroom, were bad in that the mother 
insisted that a number of the household be present during the operation, ' ' to 
make sure that everything would be all right." 

The onset of the convulsive seizures 25 months following the operation 
merely indicates that the patient only apparently recovered and that there 
was undoubtedly not only a persistent increased intracranial pressure due 
to the resulting cerebral edema, but that the extradural hemorrhage had 
only been partially removed, so that it produced an irritation of the under- 
lying cortex and eventually the convulsive seizures. It is most unfortunate 
that the more extensive operation of right subtemporal decompression and 
then the removal of the extradural clot could not have been performed in a 
hospital under modern aseptic conditions, nr an attempt made even in the 
patient's home to perform this operation with proper assistance and under 
strict aseptic precautions ; it was impossible, however, to obtain the consent 
of the mother for this more extensive procedure (even though the patient 
himself desired it, but, as he said, ' i I must obey my mother ' ' — a remarkable 
instance of the filial obedience of the Chinese as a race), and it required 
over a week to obtain the permission of the mother even for this minor 
exploratory incision of the scalp ; at the time, it was still hoped that, after 
the scalp incision had been made, a small trephine opening could then be 
performed and the condition, if an extradural hemorrhage, could be thus 
drained with little or no risk to the patient; the presence of such a wide 
fracture of the underlying vault was not even suspected. Since this opera- 
tion, it has been demonstrated upon a number of patients that a trephine 
opening of the vault can be made under local anesthesia of the overlying 
scalp with very little pain to the patient until the dura is reached; 
the dura itself is very sensitive. (Upon my return to Pekin following 
the operation, I gave my word to the patient's father, the President of 
China, and at his request, that I should not mention anything to anyone 
about the operation upon his son— his eldest boy and the probable successor 
to the throne. The death of both the father and on the same day of the 
patient himself, frees me of this promise so that I am now publishing in 
book form a brief account of my experience in the summer home of this 
Chinese potentate amid Oriental splendor.) 

B. Recent depressed fractures of the vault. 

1. No operation. 

Case 15. — Recent depressed fracture of the vault. Operation refused. 
Recovery doubtful. 

No. 13. — Gus. Fifty-four years. "White. Married. Longshoreman. Norway. 

Admitted February 5, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Discharged February 7, 1914 — 2 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While loading a ship, patient was struck by the chain 
of a crane ; unconscious for several minutes. Brought to the hospital in the 
ambulance. 



ACUTE BRAIN INJURIES 179 

Examination upon admission (1 hour after injury). — Temperature, 
100.4°; pulse, 100; respiration, 20; blood-pressure, 126. Comatose; not 
alcoholic. Two stellate lacerations over right side of head ; careful probing 
of upper wound reveals 2 small depressions of 1 cm. in diameter — outer 
table of the skull only considered to be involved. No bleeding from nose, 
mouth or ears; no mastoid ecchymosis. Pupils equal and react normally. 
Reflexes negative. Fundi — retinal veins possibly enlarged; nasal margins 
of optic disks slightly blurred by edema. Lumbar puncture not performed. 
X-ray (Doctor A. J. Quimby) — "depressed fracture (punctate) of right 
parietal bone. " Urine negative. 

Treatment. — Expectant palliative ; scalp laceration widely shaved, 
cleansed and loosely sutured ; 2 drains of rubber tissue inserted. 

Examination at discharge (2 days after admission). — Temperature, 
98.6°; pulse, 80; respiration, 20; blood-pressure, 138. Patient has refused 
all treatment and insists upon "going home"; refuses to permit the ele- 
vation of the depressed area of bone to prevent future complications. 
Reflexes negative. Fundi — retinal veins still enlarged ; edematous blurring 
along the nasal margins of both optic disks. 

Treatment. — Patient advised to refrain from work for at least a month 
and to return at frequent intervals for examination. 

Examination (May 28, 1914 — 3 months after injury). — No complaints; 
working as usual. Reflexes negative. Fundi negative. Small depressed 
area of bone over right parietal bone can be easily palpated ; not tender. 

Examination (September 2, 1916 — 31 months after injury). — No com- 
plaints ; " as well as ever. ' ' Reflexes negative. Fundi negative. 

Examination (June 17, 1918 — 52 months after injury). — No complaints; 
patient, however, is decidedly alcoholic. Reflexes — knee-jerks obtained with 
difficulty, requiring reinforcement ; no Babinski ; abdominal reflexes absent. 
Fundi — general suffusion of entire retina?; no definite edema about optic 
disk margins. 

Remarks. — Whether this patient will remain "perfectly well" is very 
doubtful, particularly if complicated by the factor of alcoholism. A 
definite depressed fracture of the vault is undoubtedly a source of local 
irritation to the underlying cerebral cortex, but if the patient is of the 
stable emotional type and the irritation is not one of severe degree, then 
it is possible for no definite signs of cortical irritability to result, especially 
if he refrains from dissipation of all kinds, and particularly alcoholic indul- 
gence. But in a patient at all unstable, or if the cortical irritation resulting 
from the depressed area of bone is marked, and especially if alcoholism bo- 
comes pronounced, then the danger of convulsive seizures and of the milder 
forms clinically of cortical irritability is very great indeed. As this patient 
has no definite signs of an increased intracranial pressure (as revealed by the 
ophthalmoscope), these fundal changes are probably due to a slight chronic 
cerebral edema resulting from the cranial injury in the presence of alcohol- 
ism, so that the risk of emotional disturbances at least and of epileptiform 
seizures, especially after a prolonged continuance of the daily use of alcohol. 
makes the prognosis very doubtful, and unless the habits of the patient 
change markedly, the danger of cerebral complications is a very great one. 



180 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

It is hoped that this patient can be followed during the next few years and 
the condition reported later. 

2. Removal of depression alone. 

Case 16. — Depressed fracture of vault ; no signs of increased intracranial 
pressure. Operative removal of depression only. Excellent recovery. 

No. 510. — Edward. Forty-five years. White. Married. Laborer'. 
Ireland. 

Admitted February 8, 1916, Polyclinic Hospital. 

Operation February 9, 1916. Removal of depressed bone. 

Discharged February 21, 1916 — 12 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While digging a ditch, patient was struck over the left 
side of the head by a shovel; no loss of consciousness. Brought to the hos- 
pital in the ambulance. 

Examination upon admission (30 minutes after injury). — Tempera- 
ture, 98.6° ; pulse, 74; respiration, 22; blood-pressure, 144. Well-developed 
Irishman in good condition ; perfectly conscious ; jokes regarding his con- 
dition as an amusing incident; no signs of shock. A curved laceration of 
the scalp of almost two inches, extending from the left parietal crest down- 
ward toward the left ear; exploration of wound with probe and gloved 
finger reveals a very definite depression of the underlying bone. No signs 
of cortical irritation or of paralysis ; no sensory impairment. No bleeding 
from nose, mouth or ears ; no mastoid ecchymoses. Pupils equal and react 
normally. Reflexes negative. Fundi negative. X-ray (Doctor W. H. 
Stewart) — "definite depression of left parietal bone near the squamo- 
parietal suture." 

Treatment. — Head prepared for operation ; entire scalp closely shaved, 
laceration cleansed with green soap, and a wet bichloride (1-5000) dressing 
applied to laceration, and a green soap poultice to the entire scalp, includ- 
ing the ears. 

Operation (14 hours after admission). — Removal of depressed area of 
bone : under y 2 per cent, novocaine local anesthesia, each angle of the 
original wound was extended about one inch, the scalp retracted and the 
underlying bone bared of periosteum ; a small button of bone, 1 cm. in diame- 
ter and similar to a trephine button, was exposed ; it was completely broken 
off from the surrounding vault and was depressed against the dura to a 
depth of 1 cm. Sufficient bone was rongeured away to permit the depressed 
fragment to be removed; dura not opened; underlying cortex apparently 
negative. Two drains of rubber tissue inserted down to dura and incision 
closed loosely with black silk; usual gauze dressing and head bandage 
applied. Duration — 18 minutes. 

Post-operative Notes. — Uneventful operative recovery; healing per 
primam. 

Examination at discharge (13 days after admission ) .v— Temperature, 
98.8°; pulse, 80; respiration, 22; blood-pressure, 138. Condition excellent. 
Laceration and operative incision healed perfectly. Reflexes negative. 



ACUTE BRAIN INJURIES 



181 



Fundi negative. A second X-ray picture "reveals a circular bony defect 
in the posterior left parietal area" (Fig. 55). 

Examination (June 20, 1917 — 16 months after injury). — No complaints; 
working as before the injury ; has been worried by pulsation at site of opera- 
tion, and this is now explained to him as being perfectly normal. Reflexes 
negative. Fundi negative. 

Last Examination (July 12, 1918). — No complaints. Site of removal of 
depressed area of bone depressed and very firm, as though being filled in 
with new bone tissue. Reflexes negative. Fundi negative. 

Remarks. — It is interesting to note the ease with which this operation was 
performed under local anesthesia and with what little pain the bone could 
be rongeured away; pulling the dura caused a definite painful sensation 
over the entire left side of the head and face — left trifacial nerve irritation. 
The use of local anesthesia 
in this case suggests the 
possibility of a still wider 
application of it for selected 
cases of cranial conditions 
in the future. This patient 
had developed no signs or 
symptoms of his head in- 
jury up to the time of 
operation and yet it was 
considered most advisable 
to remove the depressed 
area of bone for fear of 
future complications — par- 
ticularly headache and the 
signs of cortical irrita- 
tion, etc. 

It is very seldom that fig. 55. 
depressed fractures in 
adults can be elevated — 

unless both tables of the vault are entirely fractured at the periphery of 
the depression and in these patients it is not wise to leave these "islands" of 
bone — they should always be removed for fear of future complications such 
as necrosis, the danger of infection and of a definite displacement of the 
fragments themselves. In the vast majority of patients the depressed area 
of the vault must be removed and in most cases it is necessary to make a 
small trephine opening at the periphery of the depressed area in order 
to enlarge the bony opening so that the depressed fragments can be removed •. 
naturally, if the underlying dura is torn it should be, if possible, sutured ; 
it may be necessary to perform a subtemporal decompression first in order 
to lessen the increased pressure so that this torn dura beneath the depressed 
fracture of the vault can be easily and safely repaired. 

In these acute depressed fractures of the vault which have a lacera- 
tion of the overlying scalp, it is of the greatest importance that this 
laceration should be cleansed most thoroughly with green soap and then the 




Circular bony defect of removal of depressed area 
of posterior portion of left parietal bone. No increase of intra- 
cranial pressure. Excellent recovery. 



182 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tissues "touched" with iodine and thus the danger of infection minimized 
as much as possible; if there is still almost certain evidence that these 
lacerated tissues are infected or will become infected, then it is better surgical 
judgment to excise them until all the infective material and possibly infected 
tissues are removed. The danger of a possible infection extending down 
through the fracture of the vault and, if the dura is torn, the great risk 
of a purulent meningitis and also cerebral abscess developing, should always 
be remembered; many of these patients develop an osteomyelitis of the 
underlying bone and if the dura is not torn, it frequently acts as a barrier 
to the direct extension of the infection intracranially, although there is 
always the risk of meningitis and less frequently of abscess formation 
developing at a later date. 

A general anesthetic was used for most of these patients having simple 
depressed fractures of the vault, but I now believe that local anesthesia 
(preferably a weak novocaine solution) would be advisable. Naturally, if 
it was necessary to perform a more extensive operation than planned origi- 
nally, then general anesthesia could be administered. Many of these 
patients are alcoholic and in poor condition physically, so that a general 
anesthetic should be avoided as much as possible for fear of pulmonary 
complications, etc. 

There are certain small depressed fractures of the vault occurring in 
the occipital region, and particularly about the sigmoid and lateral sinuses, 
and also over the torcula, when it is better surgical judgment to "let them 
alone" rather than to attempt their removal and possibly have the com- 
plication of severe hemorrhage ; naturally, if there are signs of their pres- 
ence intracranially, then they should be removed and the injured sinus 
packed or ligated. It is surprising that the longitudinal sinus is rarely torn 
by depressed fractures of the vault overlying the sinus, and that these areas 
of depressed bone can usually be removed without any complication of 
hemorrhage from the sinus itself. I believe that all depressed fractures 
of the vault should be elevated or removed, whenever possible surgically, 
for fear of future complications. 

Recent Mild Brain Injuries Associated with a Fracture of the Base 
of the Skull and with Signs of an Increased Intracranial Pressure. 
No Operation. 

In many patients having severe cranial injuries, the fracture of the base 
of the skull is the main pathology resulting, and therefore these cases may 
be labelled as fractures of the base of the skull. The intracranial contents 
may be little if any damaged, so that if an increased intracranial pressure 
does occur it is usually of such a mild degree that the expectant palliative 
treatment alone is sufficient to obtain an excellent recovery, both of life 
and of future normality; if, however, the intracranial lesion has produced 
a marked increase of the intracranial pressure, whether due to hemorrhage 
or cerebral edema, then the greatest care must be exercised in determining 
whether the expectant palliative treatment will be sufficient or the necessity 
of the mechanical relief of this increased pressure by means of the cranial 
operation of decompression in order to secure the best result. The presence 






ACUTE BRAIN INJURIES 183 

of the fracture of the base is really of little concern in the treatment unless 
the discharge of blood and cerebrospinal fluid through the line of fracture 
into the nose or ears materially lessens the increased intracranial pressure ; 
with appropriate precautions in these latter patients, the danger of infec- 
tion is slight. 

The diagnosis of cranial injuries sufficient to produce a fracture of the 
base of the skull is frequently facilitated by the line of fracture passing into 
either middle ear with a rupture of the tympanic membrane, or into the crib- 
riform plate of the frontal bone so that blood, and especially cerebrospinal 
fluid, are discharged into the external auditory canal and nares respectively ; 
fractures of the base subtentorially extending into the naso-pharynx, such 
as those of the basilar process of the occipital bone, are also most serious ones 
on account of the great danger of infection, while fractures into or around 
the foramen magnum may cause so much hemorrhage subtentorially that a 
direct compression of the medulla itself frequently results. Fractures of the 
base extending into either orbit usually cause an escape of blood into the 
tissues of the orbit and thus ecchymosis of extreme degree may occur; 
subconjunctival hemorrhages are also of common occurrence but they are not 
pathognomonic of an adjacent fracture of the orbital bones. Kontgenograms 
are rarely of value in the diagnosis of basal fractures ; if, however, positive 
pictures can be obtained — particularly of the occipital bone about the 
foramen magnum by means of the open mouth, the gravity of the patient 's 
condition could thus be early recognized and all appropriate measures insti- 
tuted to lessen the danger of subtentorial complications. 

The majority of the patients having a fracture of the base of the skull 
do not disclose the signs of a marked increase of the intracranial pressure 
and therefore they make excellent recoveries under the expectant palliative 
treatment alone. It is in those patients, however, in whom the ophthalmo- 
scope reveals an early papilledema with blurring of the nasal halves and 
even the temporal halves of the optic disks, and the spinal mercurial mano- 
meter registers the pressure of the cerebrospinal fluid as being 16 mm. 
and even higher — these are the patients for whom the expectant palliative 
treatment is not a safe and rational method of treatment — not only as con- 
cerns the immediate life of the patient but also his future condition of good 
health; in these patients, the operation of decompression and drainage is 
the safer procedure to obtain the best immediate and ultimate result — 
whether the increased intracranial pressure is due to hemorrhage or cerebral 
edema. Naturally, cerebral contusions and lacerations, either directly over- 
lying the line of fracture or more usually of the "contre-eoup" type to the 
point of contact — these complications and their manifestations of paralysis, 
impaired sensation, etc., can be improved by the treatment but not wholly 
eradicated on account of the non-regeneration of cerebral tissue — the cor- 
tical nerve cells and the non-medullated subcortical nerve fibres: the nerve 
tissues not primarily destroyed but merely functionally compressed — these 
tissues can regain their normal function with the appropriate treatment so 
that a marked improvement can thus be obtained. 



1 84 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Recent fractures of base of the skull; signs of increased intracranial pres- 
sure. No operation. Recovery. 

A. Mild increase of the intracranial pressure. 

a. Excellent recovery. 

Case 17. — Fracture of base of skull; signs of a mild increase of the 
intracranial pressure. No operation; repeated lumbar punctures. Excel- 
lent recovery. 

No. 344. — Thomas. Thirty-one years. White. Single. Clerk. U. S. 

Admitted August 23, 1915, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Discharged September 12, 1915 — 19 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — After coming out of a store, patient was struck over the 
head by an unknown man with a baseball bat ; knocked down (bat breaking) 
and was unconscious for several minutes; brought to the hospital in 
the ambulance. 

Examination upon admission (25 minutes after injury). — Tempera- 
ture, 98.2°; pulse, 80; respiration, 24; blood-pressure, 132. Semiconscious 
and in very little shock. Laceration of scalp over left frontal bone and also 
over the occipital protuberance. Profuse hemorrhage from nose and bloody 
cerebrospinal fluid dropping from right ear; right mastoid ecchymosis. 
Pupils equal and react normally; nystagmoid twitches to right. Reflexes 
negative. Fundi negative. Lumbar puncture — cerebrospinal fluid bloody 
and under a slight pressure (approximately 10 mm.). 

Treatment. — Expectant palliative ; lacerations of scalp shaved widely, 
thoroughly cleansed and loosely sutured with fine black silk; 2 drains of 
rubber tissue inserted. 

Examination (30 hours after admission). — Temperature, 100.2°; pulse, 
84; respiration, 24; blood-pressure, 136. Conscious; complains of severe 
headache "all over." Bleeding from nose has ceased, but cerebrospinal 
fluid appears at intervals in the right external auditory canal. Pupils 
equal and react normally; nystagmoid twitches to right have disappeared. 
Reflexes negative. Fundi — retinal veins enlarged ; an indistinct blurring of 
the nasal margins of both optic disks. Lumbar puncture — cerebrospinal fluid 
bloody and under slightly increased pressure (approximately 10 mm.) . X-ray 
(Doctor J. A. Quimby) — "no fracture of the skull can be ascertained." 

Treatment. — Expectant palliative; lumbar puncture with drainage of 
15 c.c. of cerebrospinal fluid was performed each day for 3 successive days — 
the last day, the cerebrospinal fluid was straw-colored and under a normal 
pressure (9 mm.) ; the headache was each time temporarily improved. 

Treatment. — Expectant palliative continued. 

Examination at discharge (19 days after admission). — Temperature. 
98.6°; pulse, 78; respiration, 18; blood-pressure, 138. General soreness 
about head but otherwise no complaints ; occasional headache. Lacerations 
of scalp healed perfectly. Otoscopic examination reveals a tear of the lower 
posterior quadrant of right tympanic membrane ; no cerebrospinal fluid is 



ACUTE BRAIN INJURIES 185 

discharging and no middle ear infection occurred. Hearing — right ear im- 
paired; bone conduction greater than air conduction. Reflexes negative. 
Fundi practically negative within physiological limits. 

Examination (January 10, 1917 — 16 months after injury). — No com- 
plaints. Reflexes negative. Fundi negative. Hearing less acute in right ear ; 
bone conduction equals air conduction. 

Last Examination (July 12, 1918 — 35 months after injury). — Patient 
thinks he is as well as ever. Reflexes negative. Fundi negative. Hearing 
possibly less acute in right ear, although bone conduction is less than 
air conduction. 

Remarks. — On account of the profuse and continuous discharge of cere- 
brospinal fluid from the right ear, it was thought advisable to perform 
repeated lumbar punctures and drainage of the excess cerebrospinal fluid 
and thus tend to lessen the discharge of cerebrospinal fluid through the ear 
and thereby decrease the chances of infection through the ear. Any pro- 
longed discharge of cerebrospinal fluid through the ear is a very dangerous, 
means of lessening the increased intracranial pressure on account of the 
danger of infection. It was interesting to observe the cessation of the dis- 
charge of cerebrospinal fluid from the ear after each lumbar puncture. 

Although this patient' was in the condition of mild shock with a tem- 
perature of 98.2°, the pulse of only 80 and a blood-pressure of 132 would 
indicate that there was an increased intracranial pressure and that the 
signs of mild shock, beside the subnormal temperature, should have included 
an increased pulse-rate of 100 and above and a lowered blood-pressure to 110 
and below, if it were not that these mild signs of shock had been over- 
shadowed and submerged by a definite increase of the intracranial pressure ; 
this was disclosed accurately by a later ophthalmoscopic examination (which 
rarely reveals signs of an increased intracranial pressure within 6 hours 
after the injury and chiefly due to this initial period of shock) and by the 
measurement of the pressure of the cerebrospinal fluid at lumbar puncture. 

In this patient the bloody cerebrospinal fluid as withdrawn at lumbar 
puncture was associated with the discharge of cerebrospinal fluid from the 
ear ; this association, however, does not necessarily follow because it is of fre- 
quent occurrence to have an intracranial subdural and subarachnoid ' ' free 
hemorrhage with or without the discharge of cerebrospinal fluid from the ear 
and yet the cerebrospinal fluid at lumbar puncture is clear and remains clear. 

The definite improvement following each therapeutic lumbar puncture 
with removal of 15 c.c. of cerebrospinal fluid is very impressive, not only 
from the subjective benefit but from the fact that at least some of the 
"free" hemorrhage must have been drained away that otherwise could not 
have been absorbed by natural means, and therefore a larger residue of con- 
nective-tissue formation and adhesions would have been possible and thus 
the danger of future complications increased. 

The gradual improvement of the hearing of the right ear of this patient is 
so frequently the history of many of these traumatic cases ; immediately fol- 
lowing the injurjr with the impairment of hearing being referred to the mid- 
dle ear on account of the fracture of the adjacent bone and a rupture of the 
tympanic membrane, then naturally bone conduction was greater than air 



1 86 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

conduction; later when the perforation of the tympanic membrane has 
healed and when there has been no permanent damage to the mechanism of 
the middle ear conductivity, then bone conduction equals air conduction and 
the acuity of hearing; increases, until finally within a period of months air 
conduction is again normally greater than bone conduction and the impair- 
ment of the infected ear can only be ascertained by most careful tests. 
Unfortunately, however, this happy result does not always occur, but it tends 
to occur in all of these patients in whom the auditory nerve itself is not 
damaged and where the anatomy of the middle ear has not been perma- 
nently impaired. 

The profuse bleeding from the right external auditory canal through a 
torn right tympanic membrane as the result of the fracture of the skull, 
and particularly of the petrous portion of the right temporal bone, made it 
possible for a large amount of intracranial "free" hemorrhage to escape 
and thus a sort of ' ' natural ' ' decompression was effected, in that the intra- 
cranial pressure was thus lessened and possibly of sufficient amount to 
permit the absorption of the remaining intracranial hemorrhage and cerebral 
edema by natural means, and thus the mechanical relief by means of a sub- 
temporal decompression and drainage was avoided. The danger of infection 
extending in these cases through the lacerated tympanic membrane and then 
intracranially through the line of fracture is to be feared, chiefly when 
attempts are made to "clean" the external auditory canal by "wiping" it 
out, syringing and other such meddlesome procedures ; naturally, if the dis- 
charge of blood or of cerebrospinal fluid should continue longer than 48 
hours, then the danger of an ascending infection with resulting meningitis 
becomes proportionally greater. The best treatment for this condition is 
absolute quiet in bed, vigorous catharsis and the application loosely of sterile 
gauze pads changed frequently, to the entire lobe of the ear; it is indeed 
rare for an ascending infection and meningitis to occur in these patients if 
the treatment as outlined above is carried out. 

Lumbar punctures were not utilized therapeutically more than once for 
this patient because the severe headache was immediately lessened following 
the lumbar puncture and withdrawal of 15 c.c. of clear cerebrospinal fluid, 
and as the mild signs of an increased intracranial pressure subsided, a 
second lumbar puncture to lower still more the intracranial pressure was 
not considered necessary. It is unusual, however, for the severe headache of 
these patients to be permanently lessened by merely one lumbar puncture. 

Although a large amount of blood was discharged from the right ear and 
presumably coming from the intracranial cavity, yet both lumbar punctures 
contained only clear cerebrospinal fluid so that either all of the "free" 
subdural or subarachnoid hemorrhage had escaped through the ear, which 
is very improbable, or the intracranial ' ' free ' ' blood had not passed down- 
ward into the spinal canal, and this latter explanation is more likely. It is 
possible, however, that the blood escaping from the ear did not come through 
the line of fracture opening into the ear but that it was due to a local 
injury of the tympanic membrane itself ; the amount of blood, however, 
was rather large for a mere local injury to the ear, but as no cerebrospinal 







ACUTE BRAIN INJURIES 187 

fluid was observed in the bloody discharge, it cannot be definitely stated that 
this blood came from the intracranial cavity. 

Case 18. — Fracture of base of the skull; signs of a mild increase of 
the intracranial pressure. No operation. Excellent recovery. 

No. 911. — Annie. Seventy years. White. Widow. Maid. Ireland. 

Admitted October 19, 1917, Polyclinic Hospital. 

Discharged November 13, 1917 — 25 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was hit by a trolley car and dragged by its 
front fender ; unconscious ; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.2°; pulse, 92; respiration, 28; blood-pressure, 120. An old but 
hardy woman ; unconscious. Fracture of outer third of left clavicle. Bleed- 
ing from the left ear; no cerebrospinal fluid observed. Paralysis of left 
side of face (peripheral type). No convulsive movements or twitchings. 
Pupils equal but react sluggishly. Reflexes — knee-jerks increased but equal ; 
no Babinski; abdominal reflexes absent. Fundi — opacities of both cornea 
prevents an accurate examination. Lumbar puncture — cerebrospinal fluid 
clear and under normal pressure (9 mm.) . Urine — slight trace of albumen ; 
otherwise negative. 

Treatment. — Expectant palliative ; appropriate position and dressing for 
fracture of the clavicle. 

Examination (20 hours after admission). — Temperature, 99.2°; pulse, 
82 ; respiration, 22 ; blood-pressure, 138. Semiconscious but can be aroused 
by speaking loudly to her. Multiple bruises over body. Bleeding from left 
ear has ceased ; otoscopic examination reveals a large laceration of posterior 
portion of the left drum; extensive left mastoid ecchymosis. Weakness 
of left side of face less marked. Pupils equal and react normally. Re- 
flexes active and equal ; no Babinski ; abdominal reflexes obtained with diffi- 
culty. Fundi — retinal veins dilated slightly but no edema about the optic 
disks, which are rather pale. X-ray (Doctor G. W. Welton) "shows fracture 
of the squamous portion of the left temporal bone extending to the base 
and involving the left auditory canal" (Fig. 56). 

Examination (7 days after admission). — Temperature, 99.4° ; pulse, 74: 
respiration, 20 ; blood-pressure, 144. Excellent improvement. Patient com- 
plains of general weakness and slight frontal headache ; general stiffness 
all over. Left mastoid ecchymosis gradually fading. Difficult to elicit weak- 
ness of left side of face by special tests. Reflexes exaggerated but equal ; no 
Babinski ; abdominal reflexes sluggish but equal. Fundi — no definite blur- 
ring of optic disk margins. 

Examination at discharge (November 13, 1917 — 25 days after admis- 
sion). — "I shall never get over the shock of the injury; I feel weak all 
over." No complaints of headache. No facial weakness can be elicited. 
Reflexes active but otherwise negative. Fundi negative. Hearing— left 
ear impaired — bone conduction being greater than air conduction. 

Last Examination (August 21, 1918 — 9 months after injury V — Xo com- 
plaints referable to injury, still feels weak in legs and back. Xo paralysis 



1 88 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



of face. Reflexes negative. Fundi negative. Hearing — left ear less acute 
than right; bone conduction, however, only equals air conduction. 

Remarks. — The paralysis of the left side of the face, which was of the 
peripheral type in that the left forehead muscles were involved, and the 
early disappearance of this facial weakness, are indicative of merely an ede- 
matous compression of the facial nerve in its bony aqueduct in the petrous 
portion about the middle ear — the usual site for peripheral lesions of the 
facial nerve ; in these traumatic cases when the skull has been fractured, a 
complete tear of the facial nerve is always to be feared, but this unfortunate 
complication occurs in only a small percentage of patients in whom there 
is a peripheral facial paralysis, because it is usually one of temporary dura- 
tion in that it results from an edematous swelling of the nerve within its 
bony canal. If the facial nerve, however, should be torn in these patients, 
and the facial paralysis may be considered permanent if no improvement 

has occurred within one year 
following the injury, then a 
peripheral anastomosis of 
one-half of the central cut 
end of the ipsolateral hypo- 
glossal nerve to the distal cut 
end of the facial nerve as it 
emerges from the stylo-mas- 
toid foramen should be con- 
sidered before the atrophy of 
the facial muscles and their 
resulting contractures should 
become extreme; this opera- 
tion of anastomosis is techni- 
cally difficult but of little 
risk to the patient, and it 
causes no facial diflgure- 
ment. 1 The clear cerebro- 
spinal fluid at lumbar puncture and yet a fracture of the skull being present 
is an interesting but a rather common observation. 

This patient has made an excellent recovery when you consider her age 
of seventy years, and yet she was in unusually good physical condition, 
so that she could withstand both the shock of such a severe injury and 
its pressure effects remarkably well ; the absence of alcohol and cardio-renal 
disease was a most important factor in her ultimate recovery. 

The otoscopic examination is a very valuable diagnostic aid in cranial 
injuries ; although in many patients there may be no escape of blood and 
cerebrospinal fluid from the ear, yet the presence of free blood within the 
middle ear, as shown by a bluish tympanic membrane, and also possibly 
the presence of cerebrospinal fluid, would indicate a fracture of the adjacent 
bone, even in the absence of a laceration of the tympanic membrane, which 
usually results and thus permits the escape of blood and cerebrospinal fluid 
from the external auditory canal. The impairment of hearing of these 
1 The operative treatment of chronic peripheral facial paralysis. J.A.M.A., May 11, 1918. 




Fig. 56. — Linear fracture of left squamous bone extending 
into left middle ear with a rupture of the left tympanic mem- 
brane. The mild increase of intracranial pressure lessened by 
the expectant palliative treatment. Excellent recovery. 



ACUTE BRAIN INJURIES 189 

patients might be lessened earlier and their ultimate recovery assured with 
more confidence if a paracentesis of the tympanic membrane is performed 
and the drainage of this blood thus made possible ; the organization of this 
blood-clot in the middle ear must cause a definite impairment of hearing — 
possibly not sufficient for the patient to be conscious of it. The danger of a 
possible infection extending through the punctured tympanic membrane 
must be remembered, but the risk is so slight with proper precautions of 
asepsis and after-treatment that it is more a question of obtaining the 
greatest recovery of hearing possible rather than the fear of a possible 
complication of infection (unless conditions are not the best and then the 
paracentesis should not be performed). 

Ecchymosis of the mastoid area not due to a direct local injury is much 
stronger evidence of an adjacent fracture of the skull than the presence 
of subconjunctival hemorrhage, which occurs very frequently without a frac- 
ture of the adjacent bones and is due to a rupture of one of the many 
subconjunctival vessels. The absence of a fracture of the skull, and par- 
ticularly of the base, merely because the X-ray pictures are negative, natur- 
ally cannot be definitely stated, and in this patient, especially when there are 
signs indicative of a fracture of the skull such as. a definite left mastoid 
ecchymosis, "free" blood in the left middle ear and also free blood in the 
cerebrospinal fluid at lumbar puncture — these facts would tend to point to 
a fracture of the skull and especially the base of the skull in the region of 
the left petrous bone — the X-ray seldom revealing lines of fracture of the 
base and in this particular area. 

Cass 19. — Fracture of base of skull ; signs of a mild increase of intra- 
cranial pressure. No operation. Excellent recovery. 

No. 722. — Patrick. Forty-five years. White. Single. Kitchen-man. 
Ireland. 

Admitted November 8, 1916, Polyclinic Hospital. 

Discharged November 23, 1916 — 15 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While at work in the hotel, patient fell into the elevator 
shaft; apparently no loss of consciousness; brought to the hospital in 
the ambulance. 

Examination upon admission (75 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 72 ; respiration, 20 ; blood-pressure, 142. Conscious but 
drowsy and stuporous. Profuse bleeding from right ear — mingled with 
cerebrospinal fluid; right mastoid ecchymosis. Right facial paralysis of 
the peripheral type. Pupils equal and react normally. Reflexes — knee- 
jerks active but equal ; no ankle clonus nor Babinski ; abdominal reflexes 
depressed but equal. Fundi negative. Lumbar puncture — blood-tinged 
cerebrospinal fluid under normal pressure (approximately 9 mm.). 

Treatment. — Expectant palliative. 

Examination (30 hours after admission). — Temperature. 99.8°; pulse, 
74; respiration, 20; blood-pressure, 144. Perfectly conscious: complains o\' 
severe frontal and occipital headache. Scanty straw-colored discharge from 
right ear (approximately 4 drops per minute') ; right mastoid area very 



i 9 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



ecchymotic and boggy. Right facial paralysis persists. Pupils equal and react 
normally. Reflexes active but otherwise negative. Fundi — slight dilatation of 
retinal veins; lower quadrant of nasal margins of optic disks indistinct. 
X-ray (Doctor W. H. Stewart) — "no fracture of the skull observed." 

Examination (4 days after admission). — Temperature, 99°; pulse, .76; 
respiration, 18 ; blood-pressure, 144. No complaints except for dull aching 
headache ; ' ' ears stopped and then my head began to ache. ' ' Straw-colored 
discharge from right ear has ceased; otoscopic examination reveals small 
laceration of the posterior lower quadrant of the right tympanic membrane ; 
left ear negative. Right facial paralysis remains the same. Reflexes active 
but otherwise equal. Fundi — retinal veins enlarged; distinct edematous 
blurring along the nasal margins of both optic disks. Lumbar puncture — 

clear cerebrospinal fluid under a slightly in- 
creased pressure (approximately 11 mm.) ; 15 c.c. 
withdrawn slowly for therapeutic effect. 

Treatment. — Expectant palliative continued ; 
massage and galvanism for the right facial muscles. 
Examination at discharge (15 days after ad- 
mission). — Temperature, 98.6° ; pulse, 70; respira- 
tion, 18 ; blood-pressure, 142. Complains of slight 
frontal headache l i in the eyes ' ' ; otherwise nega- 
tive. No discharge from right ear ; right mastoid 
area still slightly discolored. Hearing impaired in 
right ear; bone conduction greater than air con- 
duction. Reflexes active but otherwise negative. 
Fundi — retinal veins slightly enlarged but the 
nasal margins of the optic disks are now clear. 
Right facial paralysis is much improved; patient 
can close the right eye and wrinkle forehead 
slightly (Fig. 57). 

Examination (September 20, 1917 — 10 months 
after injury). — "Well as ever," except for a slight dizziness when stooping. 
Reflexes active but otherwise negative. Fundi negative. Hearing — right 
ear impaired; bone conduction slightly greater than air conduction. No 
right facial weakness can be elicited. 

Last Examination (July 29, 1918 — 20 months after injury). — No com- 
plaints except apparently an increasing alcoholism. Reflexes negative. 
Fundi negative. Hearing — right ear still impaired; bone conduction still 
greater than air conduction. Facial musculature normal. 

Remarks. — Although the X-ray picture did not reveal a line of fracture 
(and it rarely does when the fracture is limited to the base of the skull, 
and particularly of the middle fossa), yet there must have been a fracture of 
the skull because cerebrospinal fluid escaped through the lacerated right 
tympanic membrane and emerged at the right auditory meatus. 

The presence of blood in the cerebrospinal fluid is merely an indication 
that the cranial injury has caused "free" blood to escape into the sub- 
arachnoid and subdural spaces — particularly the former; the converse is 
not true, however, because clear cerebrospinal fluid is frequently obtained at 




Fig. 57. — Right facial par- 
esis following a complete right 
facial paralysis of the periph- 
eral type and most probably 
due to an edematous compres- 
sion of the right facial nerve in 
its bony canal adjacent to the 
middle ear. Entire recovery. 



ACUTE BRAIN INJURIES igr 

lumbar puncture in patients having a large amount of "free" hemorrhage, 
both subarachnoid and subdurally. A fracture of the skull may be present 
or not — the intracranial hemorrhage is not dependent upon whether a 
fracture of the skull is present or not. It would seem to be unusual, how- 
ever, for an extensive fracture of the skull to occur, and especially of the 
base of the skull to which the dura is adherent, without causing some ' ' free ' ' 
blood to escape into the subdural or subarachnoid spaces due to a rupture 
of one or more small vessels; if of small amount, this bleeding is of little 
importance clinically, as it can be absorbed by "natural" means, and it 
is only when it is associated with a marked cerebral edema or when the 
hemorrhage itself is of large amount, that the signs of a marked increase 
of the intracranial pressure necessitates a mechanical relief of this intra- 
cranial pressure by means of the subtemporal decompression and drainage. 

The statement and excellent observation of the patient that ' ' ears stopped 
and then my head began to ache" are most interesting and undoubtedly 
correct, because the escape of blood and of cerebrospinal fluid from the 
right ear permitted a lessening of the intracranial pressure and thus no 
severe headache occurred, but when this exit for the cerebrospinal fluid 
became blocked, then the intracranial pressure increased until the patient 
had definite pain throughout the head as a result of this increased intra- 
cranial pressure expanding and stretching the dura. It was for this reason 
that a second lumbar puncture was performed and 15 c.c. of cerebrospinal 
fluid removed, and by thus again lessening the increased intracranial pres- 
sure, the headache was relieved for a period of almost 8 hours. 

If it were not for the danger of infection extending through the lacerated 
tympanic membrane and then intracranially through the line of fracture 
with a resulting purulent meningitis, it would always be advisable for the 
discharge of cerebrospinal fluid through the ear to continue for a number 
of days until any increase of the intracranial pressure would be entirely 
relieved; such drainage afforded by the escape of a large amount of the 
cerebrospinal fluid and of the intracranial hemorrhage would obviate the 
necessity of cranial operations upon these patients in all but the most 
severe and extreme conditions. On account of this danger of infection, if 
the discharge of blood and particularly of cerebrospinal fluid has continued 
longer than 48 hours, it is frequently advisable to perform repeated lumbar 
punctures daily and 15-20 c.c. slowly removed each time, in order by this 
means of drainage to lessen the increased intracranial pressure and thus 
permit the opening in the line of fracture through the ear to become closed 
and thereby lessening the danger of infection through that channel. 

The right facial paralysis of the peripheral type (as indicated by the 
muscles of the right half of the forehead being involved) was most probably 
due to an edematous compression of the right facial nerve itself in the bony 
aqueduct adjacent to the right tympanum ; its complete recovery of function 
would confirm this belief. This type of edematous compression of the facia] 
nerve is the most common form following cranial injuries. It is rare for the 
facial nerve to be completely severed as the result of the line of fracture 
passing through the bony canal of the facial nerve. 

Case 20. — Acute severe brain injury associated with mild signs of 



192 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

increased intracranial pressure and a possible fracture of the base of the 
skull. No operation. Symptoms and signs persisting for one year and then 
an excellent recovery. 

No. 056. — Harriet. Forty-eight years. White. Married. Housework. U. S. 

Admitted June 9, 1913, White Plains Hospital. Consultation June 11, 
1913 — 2 days after injury. Referred by Doctor G. S. Amsden, White Plains. 

Discharged July 18, 1913 — 39 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While driving an automobile, patient had a collision, 
throwing her from the car and striking her head against the ground; 
immediate loss of consciousness; taken to the hospital in the automobile 
where, upon admission (30 minutes later), the temperature was 100, pulse 
90 and respiration 24; there was no bleeding from nose, mouth or ears; 
knee-jerks were much exaggerated but equal, and there was present a 
double Babinski. 

Treatment. — Expectant palliative. 

Consultation with Doctor Amsden on June 11, 1913 — 2 days after in- 
jury. — Temperature, 99.8°; pulse, 94; respiration, 22; blood-pressure, 146. 
Well-nourished and developed. Unconscious, but could be roused by firm 
supra-orbital pressure, although unable to reply to questions. No paralyses 
elicited. Right subconjunctival hemorrhage, right orbital and right mastoid 
ecchymoses ; no clotted blood in nares or external auditory canals. Pupils 
equal and react normally. Reflexes — patellar exaggerated, left possibly 
greater than right ; no ankle clonus but loft Babinski ; abdominal reflexes 
not obtained (abdominal wall being rather fat and. pendulous). Fundi — ■ 
retinal veins dilated; nasal halves of both optic disks blurred by edema, 
right possibly more than left. Lumbar puncture — blood-tinged cerebro- 
spinal fluid under increased pressure (approximately 15 mm.). 

Treatment. — The following note was made by me and attached at that 
time to the history of the patient : " As it seems that the condition of the 
patient is improving, especially the unconsciousness, which was becoming 
lighter — more of a comatose condition, I do not urge an immediate decom- 
pression, although I consider it advisable — not for fear the patient will die, 
but rather to avoid post-traumatic conditions." It was decided to await 
developments. Usual expectant palliative treatment. 

Consultation with Doctor Amsden (June 14, 1913 — 5 days after injury). 
— Temperature, 99° ; pulse, 84 ; respiration, 22 ; blood-pressure, 140. Patient 
is now conscious — complaining of severe headache. Marked paraphasia — 
sensory as well as motor. Pupils equal and react normally. Reflexes — 
patellar exaggerated, left possibly greater than right; no ankle clonus and 
the left Babinski is now easily exhausted; abdominal reflexes cannot be 
obtained. Fundi — retinal veins dilated; nasal halves of both optic disks 
blurred as at preceding examination. 

Treatment. — Expectant palliative. Patient made a gradual recovery; 
complained of dull persistent headache. Paraphasia continued for 2 weeks ; 
amnesia present for 20 days and then gradually improved. Patient easily 
fatigued and distressed by any noise. Poor memory for proper names per- 



ACUTE BRAIN INJURIES i 93 

sisted after discharge on the thirty-ninth day following injury ; at that time, 
the reflexes were increased but equal and there was no Babinski present. 

Examination (January 1, 1914 — almost 7 months after injury). — A 
definite improvement has occurred; it is only when tired that patient 
complains of discomfort in the head — a sense of pressure ; occasional spells 
of dizziness; restlessness with insomnia at times. Rarely perseveration in 
the use of words. Memory for proper names still impaired. No marked 
changes in temperament — possibly more irritable. Slight tremor, with mild 
ataxia, of both hands, especially the left; tendency to positive Romberg. 
Pupils equal and react normally. Reflexes — patellar active but equal; 
no ankle clonus nor Babinski. Fundi — retinal veins not abnormally dilated, 
although the vessel walls appear slightly thickened; slight haziness about 
nasal margins of both optic disks which are rather pale ; both physiological 
cups are shallow from new tissue formation. 

Examination (June 1, 1914 — 12 months after injury). — Patient still 
complains of heaviness and fulness in the head, especially upon exertion or 
when fatigued. No definite changes in personality; memory for recent 
events not so good as before the injury; slight paraphasia at times — fre- 
quently unable to use well-known words. Pupils equal and react normally. 
Reflexes — patellar very active but equal; no ankle clonus nor Babinski. 
Fundi same as at preceding examination. No impairment of vision other 
than a subjective blurring and haziness. The following note was made by 
me at this time upon the patient 's history : " It will be most interesting to 
observe this patient for a number of years in order to ascertain the per- 
manent impairment ; she may entirely recover and yet it would be surprising 
if she did so; post-traumatic conditions in this type of patient are most 
persistent. I now feel that I should have advised a cranial decompression 
at my first examination more vigorously than I did ; in my opinion, it would 
have been the safer procedure. ' ' 

Examination (September 20, 1915 — 27 months after injury). — During 
the past year patient has made such a marked improvement that she may be 
considered as practically well ; no longer has headaches, and it is rare for 
her to have even a feeling of fulness in the head. The memory has become 
more normal and there is no longer a paraphasia. In almost every way. 
patient is the same as before the injury. Reflexes active but otherwise 
negative. Fundi — retinal veins of normal size, although their walls are 
thickened by new tissue formation; no edematous blurring of details of 
optic disks ; new tissue formation naturally persists. 

Last Report (September 22, 1918 — 63 months after injury). — Husband 
states that patient is a well woman "in every way''; no complaints except 
for an occasional dull headache; no change of personality and no emo- 
tional impairment. No difficulty of speech and memory is now excellent. 

Remarks. — This has been a most interesting case to follow in that at the 
time of the injury and during the first year following it. it appeared 
that the patient was not going to regain her former good health as before 
the injury; the persistence of the signs of a mild increase of the intracranial 
pressure for the period of one year following the injury made me feel at 
the time that the condition would probably be a permanent one. The rapid 
13 



i 9 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

improvement mentally, emotionally and physically, following the adjust- 
ment of a slight domestic annoyance was, I believe, a definite factor in 
causing this marked improvement to occur. 

It would seem that this patient had had a chronic cerebral edema asso- 
ciated with a mild intracranial hemorrhage — there being no fracture of the 
skull demonstrated, although it may have been present, and that the period 
of time necessary for the cerebral edema to be absorbed was in this patient 
a little over one year ; a rigid and strict expectant palliative treatment was 
administered throughout her convalescence, and I believe that this careful 
medical supervision was an important factor in her ultimate recovery. In 
many respects the post-traumatic history of this patient is unusual, for it is 
most rare for patients to recover ultimately so well after their symptoms 
and signs have persisted for a period of one year after the injury; it is 
.for this reason that I still feel that it is the safer procedure to perform a 
subtemporal decompression upon patients similarly affected as this patient, 
for the risk of the operation is slight compared with the great danger of the 
many post-traumatic complications, and even if an occasional patient, 
just as this patient, should make an excellent recovery even if the operation 
to relieve the increased intracranial pressure had not been performed, yet 
the risk to which the majority of these patients would be exposed (and I 
believe the average would be as high as 9 out of 10) is a far greater danger 
than the slight risk of the operation itself, and the benefit following the 
operation would be immediate, whereas even in the occasional fortunate 
patient of this type who finally recovers the former good health without an 
operation, the period of time necessary for the convalescence is usually the 
same as for this patient — an average of 12 months. 

b. Doubtful recovery. 

Case 21. — Fracture of base of skull; signs of a mild increase of the 
intracranial pressure. No operation ; repeated lumbar punctures. Doubt- 
ful recovery. 

No. 181. — Matilda. Sixty-seven years. White. Single. Retired school 
teacher. U. S. 

Admitted March 11, 1915, Polyclinic Hospital. Referred by Doctor 
W. A. Scruton. 

Discharged April 6, 1915 — 26 days after injury. 

Family history negative. 

Personal history negative ; always well and strong. 

Present Illness. — On night before admission, patient fell down a flight 
of stairs while chasing a burglar ; has been unconscious since the accident ; 
brought to the hospital in the ambulance. 

Examination upon admission (18 hours after injury). — Temperature, 
99.4° ; pulse, 88 ; respiration, 28 ; blood-pressure, 148. Patient could be 
roused to semiconsciousness at intervals; could not talk intelligibly; did 
not recognize surroundings; tendency to drawl, rhyme and whine what 
words she spoke, such as die, try, by, etc. Nothing she said had any sense, 
but upon being aroused the sensation of stimulation would apparently cause 
her to rhyme other words ; the sensation of moisture following the expelling of 
an enema caused her to say "I am wet," and immediately after to make 



ACUTE BRAIN INJURIES 195 

another sentence of no particular meaning, but of the same length, and all 
ending with a word rhyming with wet, as bet, let, set, etc. Well-developed 
and nourished for her age. Laceration of about Sy 2 inches long over left 
occipito-parietal region extending down to the bone. This had been sutured 
and drained by the physician who had attended patient immediately after the 
fall. Slight laceration of right orbital region and marked ecchymoses about 
both eyes; left eye nearly closed. Clotted blood in left auditory canal; 
marked left mastoid ecchymosis ; otoscopic examination revealed a laceration 
of the left ear drum. Lumbar puncture — cerebrospinal fluid clear and 
under a slightly increased pressure (approximately 11 mm.). X-ray 
(Doctor A. J. Quimby) — "no line of fracture to be observed." Pupils 
equal but react sluggishly. No facial paralysis. Reflexes — knee-jerks equal 
and not much exaggerated; no Oppenheim, Gordon, Babinski or ankle 
clonus ; abdominal reflexes not obtained. Eye grounds show no appreciable 
blurring; retinal vessels of normal size. 

Treatment. — Expectant palliative. 

Examination (7 days after admission). — Temperature, 99°; pulse, 82; 
respiration, 26 ; blood-pressure, 146. Patient has remained in a dazed con- 
dition during past week; very delirious at times; refused all medications 
and screamed loudly at all attempts to aid her. At end of this time she 
improved somewhat mentally; recognized her brother but could not talk 
coherently; cried and screamed for no apparent reason and talked non- 
sense continually. Reflexes active but otherwise negative. Fundi — retinal 
veins enlarged; otherwise negative. Repeated lumbar punctures upon 5 
successive days allowed each time 20 c.c. of clear cerebrospinal fluid to drain 
off under slightly increased pressure ; the patient became quieter and would 
even sleep within an hour after each puncture. During the following week 
the improvement was not so marked; laceration had entirely healed per pri- 
mam, but she complained of pain in that area and general headache ; could 
read and at times talk fairly sensibly, but soon would run off into delirious 
chatter. Physical examination was practically negative ; reflexes active 
but otherwise negative. Fundi — retinal veins slightly enlarged but other- 
wise negative. Lumbar puncture (15 days after admission) — cerebrospinal 
fluid clear but ran out under a slightly increased pressure (approximately 
11 mm.). 

Examination at discharge (25 days after admission). — Temperature, 
98.8° ; pulse, 80; respiration, 24; blood-pressure, 146. Much better in every 
way ; clearer mentally but still confused, repeating, ' * I must go to the school 
to my pupils" and "I am old enough to be your mother and you must let 
me go to the school." (Patient has not taught school for 6 years.) Persever- 
ation of words is not present nor any motor or sensory aphasia, but a sort 
of " senile chatter" and a childishness .which were not present before the head 
injury. Reflexes active but not abnormal. Fundi negative. 

Examination (August 24, 1917 — 28 months after injury ). — Patient has 
come to me repeatedly for examinations during the past 2 years: very much 
improved mentally and emotionally, although never having as normal a 
mental condition as before the injury. Has become very irritable ami "very 
difficult to live with." Reflexes negative. Fundi negative. 



i 9 6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Last Report (December 12, 1919 — 56 months after injury). — Patient 
resides in a " home for old and indigent teachers. " " Possibly more irritable 
hut otherwise very much as before the injury." 

Remarks. — It would seem in this patient that the head injury produced 
an acute condition of "wet" brain so that this condition, associated with 
her age, produced the mental and emotional instability. It will be very 
instructive and important to obtain a post-mortem examination later. 

The clotted blood in the left auditory canal associated with a laceration 
of the left tympanic membrane (as revealed by otoscopic examinations), and 
the distinct ecchymosis of the left mastoid area would indicate a fracture of 
the base of skull in the region of the petrous portion of the left temporal bone ; 
the absence of blood in the cerebrospinal fluid and the negative rontgeno- 
gram would not exclude a fracture of the skull from being present in this 
area of the base of the skull. 

It was interesting to observe the temporary periods of relief, both of 
the mild delirium and general restlessness, following each of the lumbar 
punctures and removal of 20 c.c. of cerebrospinal fluid; the patient would 
almost immediately become quiet and within one-half hour gradually fall 
asleep; this restful period might continue for 4 to 8 hours, when upon 
awakening the patient would again become noisy and require restraint. This 
persistent cerebral edema was undoubtedly the cause of her mental and emo- 
tional instability to which she was more susceptible on account of her age. 

Case 22. — Fracture of base of skull; signs of a mild increase of 
intracranial pressure. No operation; repeated lumbar punctures. Doubt- 
ful recovery. 

No. 170. — Robert. Forty-two years. White. Married. Laborer. 
Ireland. 

Admitted August 26, 1915, Polyclinic Hospital. Referred by Doctor 
Alexander Lyle. 

Discharged September 12, 1915 — 16 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was hit by an automo- 
bile ; unconscious ; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 97.8° ; pulse, 84; respiration, 24; blood-pressure, 132. Well-developed 
and nourished; unconscious and in shock. Bleeding profusely from nose 
and both ears; no mastoid ecchymosis. Pupils equally dilated and react 
to light sluggishly. Reflexes difficult to elicit, but no ankle clonus nor 
Babinski ; abdominal reflexes absent. Fundi negative. 

Treatment. — Expectant palliative. 

Examination (10 hours after admission). — Temperature, 99.8°; pulse, 
72 ; respiration, 18 ; blood-pressure, 142. Unconscious ; respiration rather 
labored. Nasal bleeding has stopped but cerebrospinal fluid continues to 
leak from both ears — the left more profusely; marked left mastoid ecchy- 
mosis. Pupils equal and react normally. Reflexes less difficult to elicit ; 
equal ; no Babinski ; abdominal reflexes not obtained. Fundi — retinal veins 
dilated; nasal margins indistinct and blurred. Lumbar puncture — blood- 



ACUTE BRAIN INJURIES 197 

tinged cerebrospinal fluid under an increased pressure of approximately 
12 mm. X-ray (Doctor A. J. Quimby) — "no line of fracture can be seen." 

Treatment. — Expectant palliative. Repeated lumbar punctures were 
performed daily for 4 days, when patient became conscious ; at each punc- 
ture 15-20 c.c. of blood-tinged cerebrospinal fluid were slowly and carefully 
removed ; pressure at the end of the puncture would frequently be less than 
one-half of the pressure before the puncture. 

Examination (6 days after admission). — Temperature, 100° ; pulse, 70; 
respiration, 18 ; blood-pressure, 144. Conscious and complains of severe 
general headache. No blood nor cerebrospinal fluid escaping from the ears ; 
otoscopic examination reveals a bilateral laceration of both tympanic mem- 
branes. Reflexes markedly exaggerated but equal; no Babinski; abdom- 
inal reflexes present and equal. Fundi— considerable dilatation of the 
retinal veins; edematous blurring of the nasal margins of the optic disks. 

Examination at discharge (16 days after admission). — Temperature, 
98.6°; pulse, 76; respiration, 20; blood-pressure, 146. Conscious and no 
complaints, except for a dull throbbing headache each morning; by noon- 
time, the headache has gone. Hearing impaired and referable to double 
middle ear involvement, bone conduction being greater than air conduction. 
Reflexes active but otherwise negative. Fundi — retinal veins still enlarged 
and the nasal margins of both optic disks are not yet distinct. 

Examination (February 12, 1917 — 18 months after injury). — Patient 
has not worked since the injury owing to almost daily headaches, early 
fatigue and general lassitude : sleeps heavily and for 14 hours at a time. 
Hearing is impaired but is better than 3 months ago. Reflexes active but 
otherwise negative. Fundi — slight dilatation of the retinal veins and also 
a slight but distinct blurring of the nasal margins of the optic disks. Lum- 
bar puncture — clear cerebrospinal fluid under a pressure of approximately 
10 mm. 

Treatment. — Light diet; daily catharsis; light work requiring very 
little physical exertion, but sufficient to keep patient's mind upon his work 
and thus tend to forget himself and troubles. 

Last Examination (August 23, 1918 — 36 months after injury). — Still 
complains of headache though not so severe as formerly; is "working" as 
a night watchman in an office. Reflexes active but otherwise negative. 
Fundi — retinal veins slightly dilated; nasal margins practically clear and 
free of edematous blurring. Patient refused a lumbar puncture to lessen 
the pressure of the cerebrospinal fluid. 

Remarks.— -It was mistaken judgment not to have advised and to have 
performed a subtemporal decompression and drainage upon this patient — 
not only to obtain a recovery of life (which was possible with merely the 
expectant palliative treatment), but to secure for the patient his former 
good health as much and as early as possible. T do not consider that the 
repeated lumbar punctures were of sufficient relief to the increased intra- 
cranial pressure in that the signs of pressure quickly returned and have 
continued in a mild degree up to the present time-, as a result of this in- 
creased pressure, he has become definitely impaired, both mentally and 
emotionally, and is no longer capable of performing a real day's work. At 



iq8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the time of the injury, it was believed that the bilateral drainage of blood 
and cerebrospinal fluid through both ears (due to a fracture through the 
middle fossa) would lessen sufficiently the increased intracranial pressure, 
and thus, not only make an operation of decompression unnecessary but 
secure a normal individual ultimately ; unfortunately, this opinion was mis- 
taken and it would undoubtedly have been better judgment to have per- 
formed the operation of subtemporal decompression and drainage as soon as 
the initial shock of the injury had disappeared. 

Case 23. — Fracture of base of skull ; signs of a mild increase of intra- 
cranial pressure. No operation. Doubtful recovery. 

No. 899.— Urling. Fifteen years. White. School. XL S. 

Examined in consultation with Doctor George D. Stewart — June 15, 
1917, 12 days after injury. 

Family history negative. 

Personal history negative, except for chorea 2 years ago. 

Present Illness. — Twelve days ago (June 3, 1917), while riding a horse, 
patient was violently thrown to the ground, striking her head; immediate 
loss of consciousness. No bleeding from the nose, mouth or ears ; no mastoid 
ecchymoses. Carried to her home in severe shock, which she survived after 
several days, but has not regained consciousness ; she has, however, become 
restless during the past 3 days and is now able to swallow liquids. Right 
hemiplegia present. Lumbar puncture, performed by Doctor Stewart on the 
second day after the injury, revealed the cerebrospinal fluid blood-tinged 
and not under abnormal pressure. 

Examination (June 15, 1917 — 12 days after injury). — Temperature, 
99.4°; pulse, 86; respiration, 26; blood-pressure, 132. Well-nourished; 
unconscious though supra-orbital pressure causes patient to struggle and 
moan ; she does not open her eyes, however. Definite paralysis of entire right 
side of body — right side of face (the right frontal muscles being but slightly, 
if at all, involved and therefore the paralysis is a cortical one) and the right 
arm and the right leg ; patient moves left side freely, but no attempt made 
to move the right side ; definite loss of speech (patient being right-handed 
and also parents and grandparents), therefore her motor speech centre is 
in the left hemisphere — the side of the brain involvement causing the right 
hemiplegia. Pupils — left larger and both pupils react to light sluggishly. 
Reflexes : knee-jerks — right greater than left ; right ankle clonus and right 
Babinski, Gordon and Oppenheim; right abdominal reflexes distinctly less 
active than left. Fundi — slight dilatation of retinal veins; distinct ede- 
matous blurring along the nasal margins of both optic disks. Lumbar punc- 
ture shows straw-colored cerebrospinal fluid not under a greatly increased 
pressure (no mercurial manometer was at hand and the cerebrospinal fluid 
was merely allowed to drop out of the puncture needle — a crude and very 
inaccurate method of estimating the pressure of the cerebrospinal fluid). 

Treatment. — Expectant palliative treatment was continued in the belief 
that the condition was one of brain laceration and not under increased 
pressure — therefore, no operation advisable; that is, the damage to the 
brain causing the hemiplegia had already occurred by a laceration of brain 



ACUTE BRAIN INJURIES 199 

tissue, and since no marked intracranial pressure was present there was 
nothing to be done except the expectant palliative treatment. 

Examination (June 22, 1917 — 19 days after injury). — Temperature, 
98.8° ; pulse, 82 ; respiration, 24. Patient has partially recovered conscious- 
ness, but is extremely drowsy — does not recognize relatives, unable to talk. 
Right hemiplegia less marked — patient now able to move right arm and right 
leg slightly and very awkwardly; no definite impairment of sensation. 
Pupils — left still larger than right and reacts sluggishly to light. Reflexes — 
patellar, right exaggerated ; distinct right patellar and right angle clonus ; 
right Babinski, Gordon and Oppenheim; abdominal reflexes — right de- 
pressed. Fundi — retinal veins enlarged; indefinite edematous blurring 
of nasal margins of both optic disks. 

Treatment. — Expectant palliative continued; general massage to right 
side of body; passive exercise. Patient did not become entirely conscious 
until 33 days after injury and patient did not speak until the 42nd day 
following injury. Unable to walk alone until October, 1917 — 4 months 
after injury. 

Examination (May 16, 1918 — 11 months after injury). — Patient has 
made a remarkably good recovery, although there is still present a definite 
weakness of the entire right side of body ; the facial weakness can only be 
elicited by special tests, while there is only a very slight lameness of the 
right leg ; right hand-grasp almost as strong as left. Slight mental retarda- 
tion but no marked emotional instability. No impairment of speech can 
be elicited by special test phrases. (Patient 's relatives are all right-handed. ) 
Pupils equal and react normally. Reflexes: patellar — right greater than 
left ; exhaustible right ankle clonus but right Babinski still present ; abdom- 
inal reflexes — right less active than left. Fundi — retinal veins possibly 
slightly enlarged; lower nasal quadrant of nasal margins of optic disks 
obscured and hazy from edema. 

Treatment. — Daily massage, both active and passive exercises ; non- 
stimulating diet — no meat, meat-soup, tea, coffee or alcohol. 

Last Examination (March 13, 1919 — 21 months after injury). — Patient 
has continued to improve in every way so that now, from a superficial 
examination, she might be considered a normal girl. Mentality, however, 
is slightly retarded in that she is very deliberate in her answers and lacks 
a certain mental alertness; no emotional impairment. No complaints what- 
ever and feels "perfectly well." Pupils equal and react normally. Re- 
flexes: patellar — right more active than left; suggestive right ankle clonus 
and right Babinski is possibly less vigorous than at last examination ; 
abdominal reflexes — right less active than left. Fundi — retinal veins pos- 
sibly larger than normal; lower nasal margins of both optic disks slightly 
blurred. X-ray (Doctor G. W. Welton) — "an irregular linear fracture of 
the right half of the occipital bone" (Fig. 58). 

Remarks. — It is a question whether a subtemporal decompression and 
drainage would have ultimately benefited this patient more than the treat- 
ment as administered. It would seem that this patient had had a definite 
cerebral laceration of the left motor cortex sufficient to cause a right hemi- 
plegia associated with a motor aphasia, but no impairment of sensation: 



2oo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



it may have resulted from a subcortical lesion but it would be most unusual 
for the lesion to have been situated in the internal capsule and yet no im- 
pairment of sensation resulting. The mild signs of an increased intracranial 
pressure could have been "taken care of" by the natural means of absorp- 
tion, and this patient would have made an excellent ultimate recovery if the 
damage and laceration to the cerebral tissue had not occurred. Naturally, 
the great danger of epileptiform seizures occurring later in the life of this 
patient is a serious one — so much so that her life should be restricted and 
limited to simple pleasures, a non-stimulating diet and the best of hygiene. 
The situation of the fracture as revealed by the rontgenogram is a most 

dangerous one, so that the 
patient was indeed fortunate 
to have recovered life itself; 
these subtentorial fractures of 
the skull radiating downward 
to the foramen magnum 
frequently produce a direct 
medullary compression by 
edema or hemorrhage, or by 
their extension into the lateral 
Dr sigmoid sinus and thus caus- 
ing a large subtentorial hemor- 
rhage to occur — and the early 
death of the patient from 
direct medullary compression. 
These patients rarely survive a 
period of time sufficient for an 
operative procedure, and even 
if they should live longer than 
several hours, the operation 
of suboccipital decompression 
and drainage is a much more 
formidable procedure than the 
simple subtemporal method. 
Most of the autopsies in my 
series of patients show a subtentorial fracture or a subtentorial hemorrhage 
and edema. 

B. Marked increase of intracranial pressure, 
a. Excellent recovery. 

Case 24. — Fracture of base of skull; marked increase of intracranial 
pressure. No operation. Excellent recovery. 

No. 25. — Harry. Seventeen years. White. Elevator boy. U. S. 
Admitted March 29, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Discharged April 12, 1914 — 14 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While walking in his sleep, patient fell out of a fourth- 




Fig. 58. — An irregular linear fracture of right half of 
occipital bone. A definite increase of the intracranial 
pressure treated by the expectant palliative method. 
Doubtful recovery. 



ACUTE BRAIN INJURIES 201 

story window into back yard; it is believed that a clothes line obstructed 
his fall ; unconscious ; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 99.6° ; pulse, 80; respiration, 24; blood-pressure, 120. Well-developed 
and nourished ; semiconscious. Left Colles fracture. Contusion, hematoma 
and laceration on right side of head with a definite tender point over right 
temple. Bleeding from both ears and nose; bilateral mastoid ecchymoses. 
Pupils moderately dilated but equal ; normal reaction. Reflexes — knee- 
jerks active — left greater than right ; left Babinski ; abdominal reflexes — 
right greater than left. Fundi — dilated retinal vessels; blurring of nasal 
margins but not of entire halves of nasal portions of both optic disks. 

Treatment. — Expectant palliative ; frequent examinations of fundi. 

Examination (14 hours after admission). — Temperature, 100.2°; pulse, 
84; respiration, 24; blood-pressure, 126. Stuporous and drowsy; remem- 
bers nothing of past night, but mind is clear on all other points. Sero- 
sanguinous discharge from both ears, and especially from the left ear. Re- 
flexes — left greater than right; no Babinski; abdominal reflexes — left de- 
pressed. Fundi — retinal vessels dilated; edema of nasal margins persists. 
Lumbar puncture — cerebrospinal fluid blood-tinged and under a definitely 
increased pressure of approximately 13 mm. X-ray (Doctor A. J. Quimby) 
— "no signs of fracture." 

Treatment. — Expectant palliative continued. 

Examination (48 hours after admission). — Temperature, 99.4°; pulse, 
78 ; respiration, 20 ; blood-pressure, 126. Conscious ; complains of dull 
headache. Aural discharge has ceased ; otoscopic examination reveals a lacer- 
ation of both tympanic membranes. Hearing definitely lessened in both ears 
— bone conduction being greater than air conduction. Reflexes — left greater 
than right; no Babinski; left abdominal reflex depressed. Fundi — retinal 
veins slightly dilated; edema along the nasal margins less distinct. 

Treatment. — Expectant palliative continued. 

Examination at discharge (14 days after admission). — Temperature. 
99° ; pulse, 80; respiration, 22; blood-pressure, 130. No complaints, except 
general weakness. Pupils equal and react normally. Reflexes increased but 
equal ; otherwise negative. Fundi — retinal veins slightly enlarged ; indefi- 
nite blurring of nasal margins of both optic disks. 

Examination (June 4, 1914 — 2 months after injury). — "All well"; 
no headache; wants permission to play baseball. Reflexes active but other- 
wise negative. Fundi negative. Otoscopic examination reveals a fibrous 
closure of the laceration of both ear drums. Hearing impaired — bone con- 
duction being greater than air conduction. 

Examination (September 12, 1916 — 30 months after injury"). — Xo com- 
plaints. Reflexes negative. Fundi negative. Hearing of both cars less 
impaired; bone conduction, however, is still greater than air conduction. 

Last Examination (August 10, 1918 — 52 months after injury). — Xo com- 
plaints. Reflexes negative. Fundi negative. Hearing of both ears impaired 
but less so — especially left; bone conduction almost equals air conduction 
in left ear. 

Remarks. — This case illustrates the value o\' the expectant palliative 



202 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

treatment of patients having even definitely increased intracranial 
pressure, especially when that pressure is due to a simple edema or increase 
in the amount of intracranial cerebrospinal fluid; especially is this true 
in patients under 30 years of age. If these marked signs of increased 
intracranial pressure do not disappear within 48 to 60 hours, then an 
operative relief of that pressure is to be considered. Although in this par- 
ticular patient it was better judgment not to have performed a subtemporal 
decompression and drainage, if this condition had occurred in a patient of 
middle age or even older, then it would have been distinctly dangerous to 
have used the expectant palliative treatment alone ; possibly repeated lum- 
bar punctures would be sufficient, but if the patient should continue to 
exhibit marked signs of an increased intracranial pressure for a period 
longer than 4 days, then a mechanical relief of this increased pressure by 
means of a subtemporal decompression and drainage would be advisable — 
being the safer procedure, not only as to the immediate recovery of life, 
but particularly an ultimate recovery of the former normal condition 
and good health. 

The profuse discharge of blood from both ears, associated with a lacera- 
tion of both tympanic membranes and an extensive ecchymosis of both 
mastoid areas — these signs indicate a fracture of the middle fossa of the 
base of the skull ; the X-ray being ' ' negative, ' ' is the usual report for such 
fractures of the base. Undoubtedly this escape of a large amount of intra- 
cranial "free" blood prevented the intracranial pressure from becoming 
severe and thus it was possible to avoid a cranial operation — the patient 
having in this manner really ' ' decompressed ' ' himself. If an infection of the 
middle ear and a possible meningitis in these patients do not occur, then 
this complication of profuse bleeding from the ears is a very fortunate one. 

Case 25. — Fracture of base of skull ; a marked increase of intracranial 
pressure. No operation. Excellent recovery. 

No. 666. — Arthur. Twelve years. White. School. England. 

Admitted September 26, 1916, Polyclinic Hospital. 

Discharged October 8, 1916 — 12 days after injury. 

Family history negative. 

Personal History. — Diphtheria five years ago; otherwise always well 
and strong. 

Present Illness. — While playing upon a one-story fire-escape, patient fell 
backward, landing upon back of head on concrete pavement; unconscious; 
brought to the hospital in the ambulance. 

Examination upon admission (45 minutes after injury). — Tempera- 
ture, 98.2° ; pulse, 92 ; respiration, 28 ; blood-pressure, 108. Well-developed 
boy; semiconscious and talking at random. While the examination was 
being made, patient had 2 slight general convulsions, each lasting 20 sec- 
onds; no localizing signs. Large hematoma over left occipito-parietal 
region. Profuse bleeding from both ears; definite mastoid ecchymosis and 
tenderness. Pupils equal and react normally. Reflexes — knee-jerks exag- 
gerated but equal; double Babinski and double exhaustible ankle clonus; 
abdominal reflexes absent. Fundi (Doctor J. A. Kearney)— "surface of 



ACUTE BRAIN INJURIES 203 

disks brick red ; nasal margins of disks slightly blurred. Vessels are normal. ' ' 

Treatment. — Expectant palliative; vigorous treatment of shock. 

Examination (10 hours after admission). — Temperature, 99.6°; pulse, 
88 ; respiration, 26 ; blood-pressure, 118. Conscious but very restless and 
irritable (requiring codeine). Left parietal hematoma, size of small egg and 
very tense. Bleeding from ears has stopped ; otoscopic examination reveals 
a laceration of both tympanic membranes. Reflexes active but otherwise 
negative ; no ankle clonus nor Babinski ; abdominal reflexes are present and 
equal. Fundi (Doctor J. A. Kearney) — "retinal veins are now enlarged; 
nasal margins of both optic disks are distinctly blurred; entire retinae, 
however, congested and of a brick red color. ' ' Lumbar puncture — cerebro- 
spinal fluid blood-tinged and under an increased pressure (approximately 
13 mm.). X-ray (Doctor W. H. Stewart) — "no fracture shown." 

Treatment. — Expectant palliative. 

Examination at discharge (12 days after admission). —Temperature, 
99.8° ; pulse, 82; respiration, 22; blood-pressure, 120. No complaints except 
"light-headed" at times. No signs of the hematoma, but both mastoid areas 
are slightly discolored. Reflexes active but otherwise negative. Fundi 
(Doctor J. A. Kearney) — "retinal vessels slightly enlarged, but no blur- 
ring edema about the disk margins." Hearing of both ears impaired — bone 
conduction being greater than air conduction. 

Examination (April 24, 1917 — 7 months after injury). — No complaints; 
going to school daily. Reflexes active but otherwise negative. Fundi nega- 
tive. Hearing only slightly impaired ; otoscopic examination reveals both 
tympanic membranes almost normal in appearance. 

Last Examination (September 10, 1918 — 24 months after injury). — No 
complaints. Hearing of normal acuity ; air conduction is greater than bone 
conduction. Otoscopic examination negative. Reflexes active but other- 
wise negative. Fundi negative. 

Remarks. — The rapid improvement of the hearing in this patient is very 
striking; even in adults similar patients recover almost normal acuity of 
hearing sometimes within one year, but in children particularly, the impair- 
ment of hearing due to a hemorrhage into the middle ear and a rupture 
of the tympanic membrane, frequently disappears within one year after 
the injury. 

It would seem that this patient had possibly "decompressed" himself 
by the profuse discharge of intracranial "free" blood through the line of 
fracture extending from the middle fossa into both middle ears; if no 
infection occurs, this is an ideal way of lessening the intracranial pressure. 

The variability of the superficial and deep reflexes is well illustrated 
in this patient and is typical of many patients having cranial injuries. 
There may be present inexhaustible ankle clonus and typical Babinski re- 
flexes and yet at a second examination one hour later, it may bo very difficult 
to elicit either, and frequently entirely impossible to do so: whether this is 
due to varying conditions of cerebral circulation and cerebral edema is not 
definitely known. In all of these patients the entire clinical symptomatology 
and signs must be considered together, and not too much importance placed 



2o 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

upon individual variations unless these latter are confirmed repeatedly upon 
successive examinations over a period of time. 

Case 26. — Fracture of base of skull; marked signs of increased intra- 
cranial pressure. No operation. Excellent recovery. 

No. 068.— Frank. Twenty years. White. Single. Student. U. S. 

Admitted September 27, 1913, Polyclinic Hospital. Referred by Doctor 
M. Allen Starr. 

Discharged October 4, 1913 — 8 days after injury. 

Family history negative. 

Personal history negative; no history of fainting spells. 

Present Illness. — During the evening, the patient had been indulging in 
all sorts of food and non-alcoholic drinks ; while riding* upon an open Sixth 
Avenue car, he suddenly felt faint, arose, and then fell headlong to the 
street ; loss of consciousness for several minutes ; brought to the hospital 
in the ambulance. 

Examination upon admission (30 minutes after injury). — Tempera- 
ture, 100° ; pulse, 98; respiration, 28; blood-pressure, 120. Well-nourished 
and developed ; semiconscious ; vomiting profusely undigested food. No 
bleeding from nose, mouth or ears ; right mastoid ecchymosis. Pupils equal 
and react normally. Reflexes all increased, but no inequality ; no Babinski ; 
abdominal reflexes present and equal. Fundi — vessels slightly dilated; 
no blurring of nasal borders of optic disks. Nystagmus (rotary) to both 
right and left. Possibly a slight weakness of right half of face. Otoscopic 
examination reveals a hemorrhage into right middle .ear, tympanic mem- 
brane, however, remaining intact. 

Treatment. — Expectant palliative. 

Examination (16 hours after admission). — Temperature, 99.4°; pulse, 
88; respiration, 24; blood-pressure, 128. Conscious; complains of severe 
headache over right side of head. Doctor John Page punctured right ear 
drum, ^allowing clotted blood and a small amount of cerebrospinal fluid to 
escape; sense of pressure over right side of head relieved, nystagmus dis- 
appeared within 3 hours and it was, therefore, undoubtedly of vestibular 
origin. Reflexes increased but otherwise negative. Fundi — enlargement 
of retinal veins with a distinct edematous blurring of the nasal margins of 
both optic disks. Lumbar puncture — cerebrospinal fluid clear and under a 
pressure of approximately 12 mm. X-ray (Doctor A. J. Quimby) — "no 
fracture observed." 

Treatment. — Expectant palliative continued. 

Examination at discharge (8 days after admission). — No complaints, 
only slight unsteadiness of both legs — cannot stand upon one leg. No 
nystagmus. No facial paralysis. Hearing of right ear impaired; bone 
conduction greater than air conduction. Pupils equal and react normally. 
Reflexes active but otherwise negative. Fundi — retinal veins slightly dilated 
but margins of both optic disks are clear. 

Examination (May 15, 1914 — 8 months after injury). — No complaints. 
Reflexes active but not abnormal. Fundi negative. Still some impairment 
of hearing of right ear and referred to the middle ear — bone conduction being 



ACUTE BRAIN INJURIES 205 

greater than air conduction; otoscopic examination reveals small irregular 
scar on right tympanic membrane. 

Examination (October 10, 1916 — 37 months after injury). — No com- 
plaints except for slight impairment of hearing of right ear; otoscopic 
examination negative. Reflexes active but otherwise negative. Fundi 
negative. 

Last Report (September 10, 1918). — Patient is with the American Expe- 
ditionary Force in France. No complaints. 

Remarks. — The impairment of hearing of the right ear is undoubtedly due 
to the new tissue formation in the middle ear, resulting from the organization 
of the former blood ; the drum was punctured after the injury in order to 
allow this blood clot to escape and therefore to lessen the amount of new 
tissue formation. In the presence of a fracture of the petrous bone, the 
procedure is associated with a certain amount of danger for fear of infec- 
tion through the incision of the tympanic membrane, and yet if the external 
auditory canal is well cleansed before the drum membrane is punctured, 
then this complication is very rare. Naturally, if the drum membrane 
has been torn at the time of the fracture, then no attempt should be made 
to cleanse the canal itself, as this procedure increases the danger of intro- 
ducing infection into the middle ear; in these patients, it usually suffices 
to cover the ear-lobe with a sterile gauze pad loosely, so that there will be 
no blockage of the canal itself. The danger of infection is greater through 
the fracture of the cribriform plate associated with nasal bleeding and a dis- 
charge of cerebrospinal fluid than in a fracture producing bleeding through 
the ear. The right facial paresis was undoubtedly due to a slight edema 
of the facial nerve in the aqueduct of Fallopius adjacent to the middle ear ; 
in rare cases, the bony wall separating the facial nerve and the middle ear 
is so thin or even absent that middle ear lesions easily compress the 
facial nerve. 

b. Doubtful recovery. 

Case 27. — Fracture of base of skull ; marked signs of an increased intra- 
cranial pressure. No operation — refused. Doubtful recovery. 

No. 095. — Daniel. Twenty-eight years. White. Married. Conductor. 
Ireland. 

Admitted December 16, 1913, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Discharged December 21, 1913 — 8 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While alighting from his trolley car, patient was struck 
by an automobile; immediate loss of consciousness; brought to the hospital 
in the ambulance. 

Examination upon admission (25 minutes after injury V — Tempera- 
ture, 98.2° ; pulse, 94; respiration, 18; blood-pressure, 126. Well-developed 
and nourished. Unconscious. Laceration of scalp over left parietal area 
No bleeding from nose, mouth or ears; left mastoid eeehymosis. Pupils — 
right larger than left ; reaction to light normal. Reflexes cannot be 



2o6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



obtained (due undoubtedly to shock) ; suggestive right Babinski, however. 
Fundi negative. 

Treatment. — Expectant palliative; vigorous shock measures instituted. 
Examination (48 hours after admission). — Temperature, 98.8°; pulse, 
58 ; respiration, 18 ; blood-pressure, 144. Conscious but very stuporous ; 
restless and complains of head pains. Pulse had dropped to 58 during pre- 
ceding 12 hours. Pupils equal and react normally. Reflexes — knee-jerks 
active, right more than left ; no ankle clonus but suggestive right Babinski ; 
abdominal reflexes present and equal. Fundi — retinal veins dilated; nasal 
halves of both optic disks obscured by edema. Lumbar puncture — cerebro- 
spinal fluid blood-tinged and under increased pressure (approximately 
14 mm.) ; 10 c.c. carefully and slowly removed. X-ray (Doctor A. J. 
Quimby) — "indefinite oblique fracture of left squamous bone" (Fig. 59). 

Treatment. — The opera- 
tion of left subtemporal de- 
compression advised to lessen 
the intracranial pressure and 
to facilitate the drainage and 
absorption of the subdural 
hemorrhage ; the operation 
was refused both by the rela- 
tives and by the patient 
himself. 

Examination at discharge 
(8 days after admission — 
patient refusing to remain in 
hospital longer). — Tempera- 
ture, 99° ; pulse, 60; respira- 
tion, 18 ; blood-pressure, 148. 
Chief complaint is headache 
and ' ' I want to go home and 
get out of here." Scalp 
therefore relatives considered him 
"practically a well man, needing only a little rest." Ecchymosis over left 
mastoid area still present ; otoscopic examination reveals both tympanic mem- 
branes negative. No paralysis. Pupils equal and react normally. Re- 
flexes all active, right greater than left ; suggestive right Babinski ; abdominal 
reflexes present and equal. Fundi — retinal veins dilated ; nasal margins of 
both optic disks obscured. 

Treatment. — Relatives and patient advised regarding diet, catharsis 
and quiet, and no work. 

Examination (January 3, 1914 — 17 days after injury). — Patient has 
resumed work; complains of slight headache and "all in all" feels fairly 
well. Laceration of scalp has healed. Pupils equal and react normally. 
Reflexes still active, right greater than left ; suggestive right Babinski still 
persists. Fundi — edematous blurring still present about the nasal margins 
of both optic disks. 

Examination (January 14, 1914 — 32 days after injury). — Patient un- 





Fig. 59. — Oblique linear fracture of left squamous bone 
associated with a left mastoid ecchymosis. A definite increase 
of the intracranial pressure treated by the expectant palliative 
method. Doubtful recovery. 



laceration healing per primam, and 



ACUTE BRAIN INJURIES 207 

able to work on account of severe headache and nausea at times; dizzy 
spells; desires an operation now (an operation was not advised at this 
time owing to the belief then held that the damage had already been done and 
that an operation would not be of any benefit to him at this late date ; we 
now know, however, and believe that a decompression operation at this time 
would have given him a definite chance of ultimate recovery) . Pupils equal 
and react normally. Reflexes — knee-jerks exaggerated, right greater than 
left; suggestive right Babinski but no ankle clonus; abdominal reflexes 
present and equal. Fundi — retinal veins enlarged; obscuration and hazi- 
ness of the nasal margins of both optic disks. 

Examination (June 5, 1914 — 6 months after injury). — Patient com- 
plains of daily headaches and inability to work. Pupils equal and react nor- 
mally. Reflexes — right more active than left ; no ankle clonus nor Babinski. 
Fundi — nasal margins of optic disks indistinct and blurred; retinal veins 
enlarged; physiological cup shallow from new tissue formation. Patient 
refused to enter hospital for lumbar puncture. 

Examination (December 2, 1916 — 36 months after injury). — Patient 
has been referred to me by a social service organization regarding his in- 
ability to work — patient just having been discharged from Blackwell's 
Island, where he has been confined for being a "loafer, common nuisance 
and vagrant'' during the past 4 months; alcoholism was also a factor. 
Patient has become enfeebled mentally and doesn't seem to realize his piti- 
ful condition ; says "I'm all right, nothing worries me." Pupils equal and 
react normally. Reflexes active but apparently equal ; no ankle clonus nor 
Babinski. Fundi — general retinal congestion and suffusion, including optic 
disks; retinal vessels all enlarged. Urine examination — heavy trace of 
albumen with numerous hyaline and granular casts. 

Treatment. — Institutional care advised. 

Last Report (Sept. 10, 1917 — 45 months after injury) . — Letter from rela- 
tives states patient died at Central Islip Insane Hospital two weeks ago ; that 
"he was never the same after the injury, took to drink and lost his mind." 

Remarks. — This is a most unfortunate case — and one which occurs only 
too frequently following the improper treatment of brain injuries. This 
patient had all the signs — and yet not severe — of increased intracranial pres- 
sure, and to a degree making most advisable the mechanical relief of the 
increased intracranial pressure by means of a subtemporal decompression 
and drainage, and yet it could not be performed and the patient thus lost 
a chance of ultimate recovery, merely because the relatives and the patient 
himself considered the injury as a trivial one. No doubt alcohol was a big 
factor in hastening the mental, emotional and physical deterioration of this 
patient, but it would seem very probable that the cranial injury with its 
resulting cerebral impairment not only weakened this patient's emotional 
control but rendered him more susceptible to the deleterious effects of alcohol. 

If a roentgenogram had not been made of this patient, it would still have 
been possible to state that a possible fracture in the region of the left tem- 
poral bone was present, chiefly on account of the left mastoid eeehymosis ; 
the absence, however, of a laceration of the left tympanic membrane or other 
left middle ear involvement would have made the diagnosis o\' fracture of 



208 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the skull very doubtful, and its presence being confirmed by the X-ray 
makes possible the definite diagnosis of a fracture of the skull. Bloody 
cerebrospinal fluid does not by any means presuppose a fracture of the 
skull, and as it is now well known the diagnosis and treatment of brain 
injuries are in no way dependent upon the presence or not of a fracture 
of the skull; the most severe cases of brain injuries frequently are not 
associated with a cranial fracture, and in many cases the presence of a 
fracture is of benefit to the patient in aiding him to lessen the increased 
intracranial pressure and thereby render unnecessary the operation of 
cranial decompression and drainage. 

Case 28. — Acute fracture of base of skull; marked signs of an increased 
intracranial pressure. No operation (refused). Doubtful recovery. 

No. 85. — Charles. Twenty-eight years. White. Single. Waiter. U. S. 

Admitted July 21, 1914, Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Discharged August 20, 1914 — 29 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While asleep, patient fell out of a fourth-story window, 
striking upon head in the back-yard (earth) ; immediate unconsciousness; 
brought to the hospital in a cab. 

Examination upon admission (2 hours after injury). — Temperature, 
97.6°; pulse, 140; respiration, 30; (blood-pressure not obtained). Well- 
developed and nourished. Unconscious and in profound shock ; cold clammy 
skin. Fracture of right tibia. Contusion and laceration over left forehead 
and hematoma of left eyelid. Pupils moderately dilated and react slug- 
gishly. Reflexes — knee-jerks increased, right more than left; suggestive 
right Babinski ; abdominal reflexes not obtained. Fundi negative. 

Treatment. — Expectant palliative ; shock measures instituted. 

Examination (30 hours after admission). — Temperature, 99.2°; pulse, 
136; respiration, 28; blood-pressure, 114. (Pulse remained 120-150 for 
three days; gradually regained consciousness on the third day.) General 
condition better, but still in severe shock. No further examination made. 

Treatment. — Expectant palliative ; shock. 

Examination (4 days after admission). — Temperature, 99.8° ; pulse, 92; 
respiration, 24; blood-pressure, 122. Semiconscious and restless. Clotted 
blood in the left auditory canal ; otoscopic examination reveals a ruptured 
left tympanic membrane. Left mastoid ecchymosis, also ecchymosis of right 
mastoid and left orbit. Pupils equal and react normally. Reflexes all active 
but otherwise negative. Fundi — nasal margins of both optic disks blurred — 
especially left disk. Lumbar puncture — cerebrospinal fluid straw-colored. 
Laboratory report (Doctor F. M. Jeffries) — "many red blood cells" — and 
under an increased pressure of approximately 14 mm. X-ray (Doctor A. J. 
Quimby) — "indistinct line of fracture of squamous portions of both tem- 
poral bones" (Fig. 60). 

Treatment. — A left subtemporal decompression advised in the belief that a 
lessening of the intracranial pressure and drainage of the blood and edema 
would be a safer procedure than the expectant palliative treatment alone. 
Operation refused. Expectant palliative treatment continued. 



ACUTE BRAIN INJURIES 



209 



Examination at discharge (29 days after admission). — Temperature, 
98.6°; pulse, 72; respiration, 20; blood-pressure, 138. Patient complains 
of dull throbbing headache which has persisted during his convalescence; 
otherwise feels "pretty good." Slight discoloration behind left mastoid 
area is still evident. Hearing of left ear less acute but otherwise negative. 
Fundi — retinal veins enlarged; nasal margins of left optic disk not so 
distinct as in right eye. 

Treatment. — Patient advised to remain at home quietly for a period 
of 3 months. 

Report (September 12, 1914 — 52 days after injury). — (Letter.) Patient 
still complains of "headache 
most of the day and night. ' ' 

Examination (October 28, 
1916—27 months after in- 
jury). — Patient is able to 
work, but still complains of 
headache and ' ' f orgetf ul- 
ness." Has been discharged 
3 times on account of trouble 
in remembering orders and 
also confusing them ; " I seem 
to be in a daze sometimes." 
Hearing of left ear less acute 
than right; bone conduction 
equals air conduction. Re- 
flexes active but otherwise 
negative. Fundi — retinal veins 
slightly enlarged; no definite 
blurring of margins of the 
optic disks. Lumbar punc- 
ture refused. 

Tno-f- 7?amnv+ ( Qor\+OTnV\oT F IG - 60- — The squamous portions of both temporal bones 

Ijabb Siepori {OepiVULUeL fractured transversely. Marked signs of an increased intra- 

10 1918 46 months after crarua l pressure; the operation of subtemporal decompression 

> refused. Doubtful recovery. 

injury) . — Sister writes: 

"Brother is doing poorly in that he is now drinking heavily and will not 

work. He says his head hurts him all the time." 

Remarks. — The increased intracranial pressure of this patient, whether 
due to a subdural and subarachnoid hemorrhage or chiefly to an acute cere- 
bral edema, should have been lessened by an early subtemporal decompres- 
sion and drainage — preferably on the fourth day after admission when 
the pulse had finally descended to 92 and the blood-pressure had risen to 
122 (indicating the survival of the period of severe shock) and when both 
the ophthalmoscopic and lumbar puncture examinations revealed a marked 
increase of the intracranial pressure. The apparent excellent recovery of 
so many of these patients following the initial loss of consciousness and severe 
shock impresses the relatives so much that they cannot understand at times 
why an operation is then necessary — "he is so well now and before he was 
dying"; if only the immediate life of the patient is concerned, this obser- 
vation is a very natural one, and it is unfortunate that many physicians 
14 




210 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

have also adopted it • it is only by following such patients over a period of 
months and even years, as in this series of cases, that we are impressed by 
the fallacy of such an attitude — in fact, it would seem that for some of these 
patients, and particularly for their relatives, it would have been more 
fortunate if the more extreme patients had died at the time of the injury, 
and it is my opinion that two-thirds of the patients having clinical histories 
in the hospitals similar to the ones in this series, never recover their former 
good health and normality. 

The continuance of the severe shock in this case is unusual ; it was only 
by means of most vigorous measures that this patient finally survived this ex- 
treme condition : continuous external warmth to the entire body by means of 
heated blankets, six hot water bags, hot black coffee and saline enemata and 
rectal irrigation alternately ; compression bandaging of both legs was used 
immediately after the patient 's admission to the hospital while the head was 
slightly lowered. (Cardiac stimulants are of very little value in these con- 
ditions of shock following cranial injuries ; whiskey, * ' hot, ' ' has occasionally 
been used in the enemata and with doubtful value.) The rontgenogram 
was rather surprising in that a fracture of the squamous portion of both 
temporal bones was revealed ; the bilateral mastoid ecchymoses, however, was 
of positive value, but only the left tympanic membrane had been lacerated, 
and it was only in the left ear that the hearing remained slightly impaired — 
even 27 months following the injury; the fact that it has persisted this 
length of time would be indicative of its permanent character. 

Case 29. — Acute fracture of base of skull ; marked increase of intracranial 
pressure. No operation. Doubtful recovery. 

No. 90. — Edna. Thirty-two years. White. Married. Housewife. U. S. 

Admitted September 19, 1914, Muhlenberg Hospital, Plainfield, N. J. 
Referred by Doctor G. W. Endicott. 

Discharged October 14, 1914 — 25 days after injury. 

Family history negative. 

Personal History. — Very athletic ; was formerly an amateur tennis cham- 
pion (singles). 

Present Illness. — Eighteen hours ago, while returning from a dance late 
last night in an automobile, patient was thrown out by a collision with 
another car; was picked up unconscious, and only regained consciousness 
during the past 6 hours. Has bled copiously from both ears, particularly 
the left one. 

Consultation with Doctor Endicott (18 hours after injury). — Tempera- 
ture, 99°; pulse, 104; respiration, 24; blood-pressure, 126. Semiconscious 
and irrational. No paralyses. Still bleeding profusely from both ears, 
especially from left ear, and it is chiefly straw-colored serum ; double mas- 
toid ecchymoses. When aroused by supra-orbital pressure, patient complains 
of intense headache. Pupils equal and react normally. Reflexes not exag- 
gerated and equal ; tendency to a right Babinski ; abdominal reflexes — right 
less than left. Fundi — retinal veins dilated; no definite blurring of nasal 
margins or halves of the optic disks. Lumbar puncture — bloody cerebro- 
spinal fluid spurted about 8 inches under high tension (no measurement 
of pressure taken). Almost 40 c.c. of the cerebrospinal fluid carefully 



ACUTE BRAIN INJURIES 211 

removed in order to lessen the increased intracranial pressure and thus to 
hasten the cessation of the aural discharge and thereby lessen the danger of 
aural infection; upon standing over night, this cerebrospinal fluid was 
one-fifth blood. 

Treatment. — Expectant palliative. (From the hospital reports, the 
patient made an excellent recovery — being discharged 25 days after 
admission.) 

Examination (December 10, 1914 — 3 months after injury). — Complains 
of headache and dizziness; impairment of hearing — left more than right. 
Pupils equal and react normally. Reflexes exaggerated but equal; no 
Babinski. Fundi — retinal veins enlarged; distinct blurring of the nasal 
margins of both optic disks. Otoscopic examination reveals an irregular 
scar upon the posterior portion of each ear drum; bone conduction is 
greater than air conduction, especially in left ear. 

Treatment. — General hygiene; patient advised to live quietly and keep 
out of all active life. 

Examination (October 21, 1917 — 37 months after injury). — Patient has 
never been really well since the injury; frequent headaches; unable to 
"play" tennis or other vigorous games for more than one-half hour on 
account of dull headache and dizzy spells; patient, however, has never 
fainted. Has become very nervous — unable to sleep and has periods of 
marked depression. Pupils equal and react normally. Reflexes very active 
but otherwise negative. Fundi — retinal veins slightly enlarged ; no distinct 
obscuration of the optic disk margins. 

Last Report (September 2, 1918 — 60 months after injury). — Practically 
the same condition as at the last examination continues. Patient's life be- 
coming more and more isolated ; she shuns her former friends and wishes to 
be alone, frequently complains of an indefinite pain in the head. 

Remarks. — At the time of the first examination of this patient — 18 hours 
after the injury — there was such a profuse discharge of bloody cerebro- 
spinal fluid in both ears that it was believed that the patient would ' ' decom- 
press" herself by lessening the increased intracranial pressure by means of 
this continuous aural discharge ; it must have been a large factor in pre- 
venting the increased intracranial pressure from becoming extreme 
and thus necessitating a subtemporal decompression in order to save the 
life of the patient or to cause a marked ultimate impairment, but it 
would seem that this means of decompression and drainage through the 
ears alone had not been entirely satisfactory in this patient, and I now 
believe that the subtemporal decompression and drainage would prob- 
ably have obtained a better ultimate recovery of tins patient's good 
health and normality. 

The definite danger of infection extending into either middle ear and then 
through the line of fracture of the adjacent bono intracranially was for- 
tunately avoided ; this is the real danger in those patients in whom the aural 
discharge continues for several days, and as an excellent moans to hasten 
its cessation and also at the same time to lesson (cxcu though temporarily) 
the increased intracranial pressure, repeated lumbar punctures may bo per- 
formed daily; it is surprising how quickly the discharge of cerebrospinal 



2i2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

fluid from the ear will cease and in this manner the risk of an otitis media 
and its complications is minimized. 

Case 30. — Acute fracture of base of skull ; marked signs of an increased 
intracranial pressure. No operation. Doubtful recovery. 

No. 244.— Arthur. Twenty-four years. White. Single. Clerk. U. S. 

Admitted May 10, 1915, Polyclinic Hospital. 

Discharged July 20, 1915 — 10 days after injury, 

Family history negative. 

Personal history negative. 

Present Illness. — While riding on the rear seat of a motor cycle, patient 
was struck by a passing automobile ; immediate loss of consciousness ; brought 
to the hospital in the automobile. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 88 ; respiration, 26 ; blood-pressure, 124. Semiconscious 
and in shock. Profuse hemorrhage from right ear while bloody cerebrospinal 
fluid welled out of left ear ; double mastoid ecchymoses. Multiple lacera- 
tions of scalp, particularly about the occiput. Pupils moderately contracted 
but equal; normal reaction to light. Reflexes negative. Fundi negative. 
No thorough examination made at this time on account of the shock. 

Treatment. — Expectant palliative; entire head shaved, lacerations 
cleansed and a warm wet bichloride (1-5000) dressing applied. 

Examination (18 hours after admission). — Temperature, 100°; pulse, 
82 ; respiration, 24 ; blood-pressure, 136. Patient stuporous ; irrational when 
aroused ; noisy. Discharge from right ear has ceased but left ear still dis- 
charging bloody cerebrospinal fluid. Definite weakness of left side of face 
(peripheral type). Pupils equal and react normally. Reflexes exaggerated 
equally and not associated with ankle clonus nor Babinski. Fundi — entire 
retinas congested and the nasal margins of optic disks obscured; retinal 
veins enlarged. Lumbar puncture — cerebrospinal fluid blood-tinged and 
under increased pressure (approximately 12 mm.). X-ray (Doctor A. J. 
Quimby) — "no line of fracture observed.' ' 

Treatment. — Expectant palliative; an operation of subtemporal decom- 
pression would possibly have benefited this patient very much indeed, but he 
made such a quick and marked improvement in the hospital that it was 
thought advisable not to perform it; this was the time, however, that an 
operation should have been performed, judging from the subsequent history 
of the patient. 

Examination (5 days after admission). — Temperature, 100°; pulse, 86; 
respiration, 22 ; blood-pressure, 136. Patient has been trying to get out of 
bed, very noisy and irrational at times, but this morning he is more quiet 
and seems perfectly conscious ; complains of pain in the head and inability 
to see out of the left eye. Straw-colored discharge from left ear ; otoscopic 
examination of right ear reveals a large tear of the tympanic membrane. 
Left facial weakness of peripheral type persists. Pupils equal and react 
normally. Reflexes equally exaggerated but otherwise negative. Fundi — 
blurring along nasal margins of both optic disks* left disk is paler than 
right (the earliest beginning of a primary optic atrophy due to a direct injury 
of the optic nerve itself) . 



ACUTE BRAIN INJURIES 213 

Treatment. — Expectant palliative. 

Examination (20 days after admission). — Temperature, 101.4°; pulse, 
88; respiration, 24; blood-pressure, 134. Feels better in every way; still 
pain over left side of head. Discharge of greenish yellow pus with an 
offensive odor from left ear. (Absolute quiet in bed advised with the usual 
dietary regulation; no irrigation of the ear permitted — a most dangerous 
procedure in these cases; merely a sterile gauze pad loosely applied over 
ear.) Reflexes active but otherwise negative. Fundi — blurring of nasal 
margins persists, right possibly greater than left; left optic disk, however, 
definitely paler than right optic disk. 

Examination at discharge (40 days after admission). — Temperature, 
99°; pulse, 80; respiration, 20; blood-pressure, 134. Feels well, although 
h^ complains of slight headache, blindness of left eye and inability to 
smell. Purulent discharge from left ear has ceased ; otoscopic examination 
reveals a laceration along the inferior margin of tympanic membrane 
which is very mucl} thickened and fibrous. Weakness of left side of the 
face still persists. Patient unable to smell and associated with its usual 
concomitant impairment — the inability to taste well. Pupils equal and 
react normally; occasional nystagmoid twitch to left. Reflexes active but 
otherwise negative. Fundi — slight edematous blurring along nasal margin 
of right optic disk ; left optic disk pale with distinct and clear margins. 

Examination (June 12, 1917 — 25 months after injury). — Impairment 
of vision of left eye persists and impairment of smell ; also 2omplains of loss 
of impairment of hearing of left ear ; otherwise feels well and is able to work. 
Left facial weakness has almost entirely disappeared. Reflexes active but 
not abnormal. Fundi — left optic disk small and pale — primary optic 
atrophy ; right fundus negative. Hearing of left ear impaired ; bone con- 
duction greater than air conduction. 

Last Examination (March 12, 1918 — 34 months after injury). — Preced- 
ing complaints persist ; patient has just been rejected by the draft board on 
account of impairment of vision of left eye, impairment of hearing, par- 
ticularly of the left ear, and loss of the sense of smell. Reflexes 
active but otherwise negative. Fundi — left primary optic atrophy ; right 
fundus negative. 

Remarks. — The ultimate condition of this patient might have been has- 
tened and also improved if an early lessening of the intracranial pressure 
had been secured early by the operation of subtemporal decompression and 
drainage ; at the time, there was such a profuse discharge of blood from the 
right ear and of bloody cerebrospinal fluid from the left ear, which continued 
for several days — so much so that the patient was in this way con- 
sidered as "decompressing" himself through the ears, and it was thought 
that the means of natural absorption would then bo sufficient for whatever 
increased pressure of cerebral edema, was left; this entire lessoning of the 
increased intracranial pressure was finally obtained after a period of months. 

The definite and prolonged weakness of the left side of the face and then 
its gradual and almost ultimate recovery would indicate a severe com- 
pression edema of the left facial nerve in the aqueduct of Fallopius due to 
a fracture of the adjacent bone. It is rare that those basal fractures of the 



2i 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

skull actually produce a complete tear of either facial nerve, although it is 
possible and does occasionally occur; the great majority of patients, how- 
ever, merely have a temporary edema of the facial nerve itself within its 
narrow canal — aqueduct of Fallopius. 

The left primary optic atrophy is probably due either to a complete tear 
of the optic nerve itself anterior to the optic chiasm, or to a bony compres- 
sion of it in the same location and of sufficient compression to produce a 
primary optic atrophy. If the site of the lesion were posterior to the optic 
chiasm and in the left optic radiations then a right homonymous hemianop- 
sia of both eyes would have occurred, whereas if the lesion were situated 
in the sella turcica and sufficient to destroy the optic chiasm, either by a tear 
or by severe bony compression, then there would have been total blindness of 
both eyes. 

The left purulent otitis media following an infection extending through 
the laceration of the left tympanic membrane was a source of great danger 
to the patient for fear that the infection might extend through the line of 
fracture of the adjacent bones and the possibility of a purulent meningitis 
and brain abscess formation resulting; fortunately the patient made an 
excellent recovery. 

Case 31. — Acute fracture of base of skull ; marked signs of an increased 
intracranial pressure. No operation. Doubtful recovery. 

No. 535. — Michael. Forty-four years. White. Married. Driver. 
Ireland. 

Admitted March 25, 1916, Polyclinic Hospital. 

Discharged May 7, 1916 — 12 days after injury. 

Family history negative. 

Personal History. — Patient has been a heavy drinker. 

First Injury. — Nine years ago, patient fell upon his head, a distance of 
6 feet, into an areaway ; immediate loss of consciousness for 3 days ; motor 
aphasia lasting 5 days; apparently no other signs of intracranial lesion; 
returned to work 2 weeks after injury. 

Second Injury. — Eight years ago severe laceration of scalp of top of 
head, but no loss of consciousness ; was able to work the following day. 

Third hi jury. — Two years ago, patient fell, breaking right tibia ; no signs 
of head injury. 

Present Illness. — Patient was found lying unconscious in the street; his 
horse and wagon were standing about 100 yards from the place of accident ; 
brought to the hospital in the ambulance. 

Examination upon admission (approximately 1 hour after injury). — 
Temperature, 97.6°; pulse, 76; respiration, 20; blood-pressure, 138. Pro- 
foundly unconscious. Extensive laceration over the occiput. Bleeding from 
the mouth due to 3 teeth having been knocked out ; no bleeding from nose 
or ears; right mastoid ecchymosis. Pupils dilated and react to light slug- 
gishly. Reflexes cannot be obtained ; no Babinski. Fundi negative. Lum- 
bar puncture — cerebrospinal fluid blood-tinged and under slightly increased 
pressure (approximately 11 mm.). 

Treatment. — Expectant palliative; scalp laceration widely shaved, 
cleansed and sutured loosely ; 2 drains of rubber tissue inserted. 



ACUTE BRAIN INJURIES 



215 



Examination (16 hours after admission). — Temperature, 99.8°; pulse, 
70; respiration, 20; blood-pressure, 142. Semiconscious; can be aroused 
easily and patient yells and attempts to get out of bed. Marked right mastoid 
ecchymosis; otoscopic examination reveals the right tympanic membrane 
bluish and bulging ; left tympanic membrane of normal appearance. Slight 
weakness of right side of face (peripheral type). Pupils equal and react 
normally. Reflexes — knee-jerks exaggerated but equal; no ankle clonus 
nor Babinski; abdominal reflexes present and equal. Fundi — retinal veins 
enlarged ; entire retinae congested but only the nasal margins of both optic 
disks obscured by edema. Lumbar puncture — cerebrospinal fluid blood- 
tinged and under a definite increase of intracranial pressure (approximately 
15 mm.). X-ray (Doctor W. H. Stewart) — "wide line of fracture of right 
occipital bone extending just to the right of the midline forward and pos- 
terior to the right mastoid 
area; old periostitis of ver- 
tex of skull" (Fig. 61). 

Treatment. — Expectant 
palliative ; no operation was 
advised in the belief that the 
patient could ' ' take care of ' ' 
the intracranial condition of 
increased pressure of hemor- 
rhage and edema by absorp- 
tion. (I feel now, however, 
that a decompression and 
drainage operation at this 
period would have resulted 
in a greater ultimate im- 
provement than was ob- 
tained by the expectant 
palliative method.) 

Examination (6 days 
after admission) . — Tem- 
perature, 99.4° ; pulse, 72 ; respiration, 18 ; blood-pressure, 140. Conscious ; 
complains of severe headache "all of the time"; mentally confused at times. 
noisy and disturbs the other patients. Right mastoid ecchymosis still 
marked. Right facial weakness has disappeared. Pupils equal and react 
normally. Reflexes very much exaggerated but otherwise negative. Fundi 
— dilatation of retinal veins ; blurring of nasal margins of optic disks per- 
sists. Lumbar puncture — cerebrospinal fluid straw-colored and under 
an increased pressure (approximately 14 mm.) ; laboratory report 
(Doctor Jeffries) — "numerous red blood-cells:" Wassermann tost — nega- 
tive. Expectant palliative treatment continued. 

Examination (20 days after admission). — Temperature. 99.4° ; pulse. ~6 ; 
respiration, 18; blood-pressure, 144. Conscious ; complains of severe head- 
ache; very drowsy and at times slightly irrational. Right mastoid ecchy- 
mosis has disappeared; right facial weakness cannot be elicited by special 
tests. Hearing — right ear impaired. Scalp laceration has healed. Reflexes 




Fig. 61. — Linear fracture of right half of occipital bone: a 
chronic periostitis of vertex of vault also disclosed. A definite 
increase of the intracranial pressure treated by the expectant 
palliative method. Doubtful recovery. 



216 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

very active but otherwise negative. Fundi — edematous blurring of nasal 
margins of optic disks still observed; general congestion of both retinae, 
however, has disappeared. 

Treatment. — On account of the occasional mental confusion of the 
patient, he was permitted to remain in the ward for a period of about 
8 weeks in the hope that his condition could be thus observed and improved ; 
merely dietetic measures were used in addition to the routine expectant 
palliative treatment. 

Examination at discharge (42 days after admission). — Temperature, 
99° ; pulse, 76 ; respiration, 18 ; blood-pressure, 138. Patient still complains 
of dull headache, especially when stooping and after eating; speaks very 
slowly, drawling out the words as in a half -daze; sleeps heavily and for 
12 and 14 hours at a time. Hearing of right ear impaired — bone conduction 
being greater than air conduction. Pupils equal and react normally. Re- 
flexes active but otherwise negative. Fundi — slight edematous blurring of 
nasal margins of both optic disks ; retinal veins still enlarged. 

Examination (September 20, 1917 — 18 months after injury). — Patient 
looks alcoholic and has an alcoholic breath. Unable to work daily, as some 
days "my head is bad." Complains of headaches, dizzy spells and loss of 
memory. Wife states that patient becomes drunk at least once a week — his 
suit for damages having been settled out of court. Pupils equal and react 
normally. Reflexes active but otherwise negative. Fundi — general retinal 
congestion, but no marked blurring of margins of optic disks. Urine exam- 
ination — trace of albumen but no casts found. 

Last Report (September 10, 1918 — 30 months after injury). — Wife 
states that the patient was taken to alcoholic ward in Bellevue Hospital one 
week ago and that he has just been transferred to Blackwell 's Island for a 
period of 3 months ; he had been drinking heavily during the past summer, 
threatening his wife with bodily injury during quarrels so that she was 
obliged to have him committed. She now, however, wishes me to help her get 
him out, but I advised her to let him remain and recommit him if necessary. 

Remarks. — This patient should undoubtedly have received the benefit of 
an early subtemporal decompression and drainage, and particularly follow- 
ing the examination, 16 hours after admission when the increased intra- 
cranial pressure was approximately 15 mm. ; this was a particularly interest- 
ing observation in that at the preceding examination upon admission to the 
hospital and while the patient was in a mild condition of shock, the intra- 
cranial pressure was only slightly increased (approximately 11 mm.), and 
the fundi were negative, whereas at this examination (16 hours later) not 
only were there now signs of pressure in the fundi as revealed by the oph- 
thalmoscope, but the measurement of the cerebrospinal fluid at lumbar 
puncture by means of the spinal mercurial manometer had risen to approxi- 
mately 15 mm. It was believed at this time that the expectant palliative 
treatment would be sufficient in aiding the absorption of this increased pres- 
sure of free hemorrhage and cerebral edema by natural means, and this 
belief was strengthened by the measurement of the intracranial pressure 
five days later (6 days after admission), when it was found to be lowered 
to approximately 14 mm. ; unfortunately a later measurement was not taken 



ACUTE BRAIN INJURIES 217 

because the patient seemed to be improving ' ' as well as could be expected ' ' — 
a very indefinite and vague opinion. 

The appearance of the right facial weakness of the peripheral type (the 
involvement of the right forehead muscles appearing gradually after 16 
hours following the injury) would indicate merely an edema of the right 
facial nerve, due to the proximity of the line of fracture of the petrous bone, 
or at least a lesion of the neighboring structures ; the otoscopic examinations 
revealing blood in the right middle ear are very suggestive of a fracture of 
the adjacent bone, and this in itself would be sufficient to produce an ede- 
matous compression of the right facial nerve within its narrow bony canal of 
the aqueduct of Fallopius. The disappearance of this facial weakness within 
6 days following the injury confirms the opinion that it was due merely to a 
temporary edematous constriction of it. 

The X-ray report of a fracture of the right occipital bone, and par- 
ticularly subtentorial, is very impressive in that these subtentorial fractures 
are most dangerous ones, as they cause so frequently subtentorial hemor- 
rhage and particularly medullary compression and edema when they radiate 
down to the foramen magnum. It is fortunate for these patients to sur- 
vive a period of 12 hours following the injury. 

Case 32. — Acute fracture of base of skull ; marked signs of an increased 
intracranial pressure. No operation; repeated lumbar punctures. Doubt- 
ful recovery. 

No. 554. — Joseph. Forty-one years. White. Married. Laborer. Italy. 

Admitted March 28, 1916, Polyclinic Hospital. 

Discharged April 16, 1916 — 18 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While patient was working upon a scaffold, he fell from 
a height of 25-30 feet to the ground ; immediate loss of consciousness ; 
brought to the hospital in the ambulance. 

Examination upon admission (35 minutes after injury). — Temperature. 
98.8°; pulse, 74; respiration, 18; blood-pressure, 138. Well-developed and 
nourished. Unconscious. Bleeding profusely from left ear ; left mastoid 
ecchymosis. Pupils dilated equally. Reflexes could not be elicited — all 
absent; cerebrospinal fluid blood-tinged and under high pressure (approxi- 
mately 15 mm.). (It is rare for this degree of pressure to occur within 6 
hours after the head injury — due to the presence of initial shock associated 
with head injuries — that is, the blood-pressure being low from the shock, 
naturally it would be difficult for intracranial bleeding to occur unless the 
torn vessel was an unusually large one; in this patient the blood- 
pressure was 138 and therefore it was possible for intracranial bleeding 
to occur early.) 

Treatment. — Expectant palliative 

Examination (14 hours after admission). — Temperature. 100.2°; pulse, 
70; respiration, 18; blood-pressnre, 136. Semiconscious and stuporous. 
Bleeding from left ear has ceased; otoscopic examination reveals a tear o\' 
the posterior portion of left tympanic membrane; right tympanic membrane 
bluish and bulging, therefore, blood in the rigM middle ear. Ecchymosis of 



si8 ^DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

both mastoid areas — right more than left. Pupils equal and react normally. 
Reflexes — knee-jerks exaggerated equally; no ankle clonus nor Babinski; 
abdominal reflexes depressed equally. Fundi — retinal veins dilated; ede- 
matous blurring; of nasal margins of both optic disks. X-ray (Doctor J. A. 
Quimby) — "no fracture can be observed." 

Treatment. — Expectant palliative ; another lumbar puncture and removal 
of 18 c.c. of blood-tinged cerebrospinal fluid performed in the hope that suffi- 
cient drainage and lessening of the intracranial pressure could be thus 
obtained. These lumbar punctures were repeated daily upon five consecutive 
days with much relief to the patient — especially a lessening of the headache, 
the stupor and mental confusion. 

Examination (6 days after admission). — Temperature, 99.8; pulse, 72; 
respiration, 18 ; blood-pressure, 140. Conscious ; complains of a severe 
frontal headache. Hearing — right ear more impaired, bone conduction 
being greater than air conduction. Pupils equal and react normally. Re- 
flexes exaggerated but equal — otherwise negative. Fundi — nasal margins of 
l)oth optic disks blurred ; retinal veins enlarged. 

Treatment. — Expectant palliative continued. 

Examination at discharge (18 days after admission). — Temperature, 
98.8° ; pulse, 78; respiration, 20; blood-pressure, 142. Complains of head- 
ache and some nausea after eating; spells of lightheadedness. Hearing of 
both ears impaired — right possibly greater than left (due to a blockage 
of blood in the middle ear — the right tympanic membrane not having been 
punctured) ; bone conduction greater than air conduction. Reflexes active 
but otherwise negative. Fundi — nasal margins indistinct and blurred; 
retinal veins enlarged. 

Examination (October 20, 1917 — 19 months after injury). — Patient able 
to work as night watchman — his duties being light. Complains of headache, 
inability to sleep and easily tired upon the least exertion. Hearing — right 
ear less acute than left ; bone conduction equals air conduction in left ear. 
Pupils equal and react normally. Reflexes active but otherwise negative. 
Fundi — retinal veins enlarged ; a slight edematous blurring along the nasal 
margins of both optic disks — not so distinct as upon discharge. 

Last Examination (July 10, 1918 — 27 months after injury). — Still work- 
ing as night watchman and is apparently satisfied with his position. "Pain 
in the head sometimes but not very bad. ' ' Is sleeping better ; unable to do 
any heavy work. Hearing — left ear almost normal ; air conduction greater 
than bone conduction, whereas in right ear bone conduction is still greater 
than air conduction. Reflexes active but otherwise negative. Fundi — 
obscuration of nasal margins still persists; practically no enlargement of 
retinal vessels. 

Remarks. — The fact that the signs of an increased intracranial pressure, 
most probably due to a chronic cerebral edema, have persisted until the 
last examination would indicate that a subtemporal decompression with 
drainage would have been the better method of treatment for this patient, 
and since this increased pressure has persisted this length of time, the hope 
of its being eventually absorbed by natural means is very remote; in the 
meantime, as the result of this increased intracranial pressure, the patient 



ACUTE BRAIN INJURIES 219 

is being impaired — a mental retardation and an emotional instability; the 
sense of early fatigue and the general physical weakness are characteristic 
of all these patients. 

The signs of initial shock so common in these patients having cranial 
injuries were overshadowed and submerged by the signs of increased intra- 
cranial pressure ; the shock, however, could not have been severe because the 
blood-pressure was 138, which would have been impossible in the state of 
severe shock as the resulting lowered blood-pressure of shock could not 
have produced a marked increase of the intracranial pressure even if a 
large intracranial vessel had been torn ; it is only when the shock is mild or 
is disappearing that it is possible for a marked increase of the intracranial 
pressure to occur. 

Although the X-ray was negative for fracture of the skull (and it is 
rarely possible for a fracture of the base, and particularly of the middle fossa, 
to be shown by the X-ray) , yet the fact that the left tympanic membrane was 
ruptured and associated w T ith a left mastoid ecchymosis, and that there was 
a hemorrhage in the right tympanic cavity as revealed by the bluish dis- 
coloration of the right tympanic membrane at the otoscopic examination and 
also associated with a right mastoid ecchymosis — these observations would 
indicate a fracture of the base of the skull extending through the middle 
fossa, or at Jeast in the petrous bones. 

The impairment of hearing, and especially the observation that the hear- 
ing of the right ear was more impaired than that of the left, and the fact 
that it was the right ear which had the hemorrhage in the tympanic cavity 
and yet the right tympanic membrane was intact but bluish and bulging — 
this observation is interesting in that there must have been a greater blockage 
to the sound transmission mechanism of the right middle ear than of the left 
middle ear, even though in the latter case the. left tympanic membrane had 
been lacerated. The persistence of a greater impairment of hearing of the 
right ear would tend to indicate that it would be better judgment to perform a 
paracentesis of the tympanic membrane in patients where a hemorrhage into 
the middle ear has occurred and yet the tympanic membrane remains intact ; 
the danger, however, of a possible infective process reaching the middle ear 
through an incised tympanic membrane and thus extending through the 
line of fracture to the meninges and even beyond — this complication should 
be carefully considered before attempting to secure the more acute hearing ; 
ordinarily, however, the danger of infection is small and it should not occur 
if the proper precautions of asepsis and sterilization are employed. 

The marked temporary improvement following each lumbar puncture 
and withdrawal of 15-20 c.c. of cerebrospinal fluid possibly made us more 
hopeful of the ultimate good result to be expected in this patient than we 
should have been; if a subtemporal decompression and drainage had been 
performed at the time the second lumbar puncture was advised as a thera- 
peutic measure, this patient would now, I believe, be a well man. From this 
standpoint, the advocacy of repeated lumbar punctures as a therapeutic 
measure should be limited to the mild cases of increased intracranial pres- 
sure, and it must not be considered as a substitute for the cranial operation 
of subtemporal decompression and drainage. 



2 2o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 33. — Acute fracture of base of skull; signs of a marked increase 
of intracranial pressure. No operation ; repeated lumbar punctures. Doubt- 
ful recovery. 

No. 581.— Daniel. Thirty-three years. White. Single. Advertising. 
United States. 

Admitted May 16, 1916, Polyclinic Hospital. 

Discharged May 28, 1916 — 12 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was found lying in the street at 2.30 a.m. in a 
condition apparently of acute alcoholism ; unconscious ; brought to the hos- 
pital in the ambulance. 

Examination upon admission (1 hour after injury). — Temperature, 
97.6°; pulse, 72; respiration, 18; blood-pressure, 128. Unconscious and in 
shock. Stertorous, heavy respiration; alcoholic breath. Extensive lacera- 
tion over left parietal area and a stab wound of right arm above the elbow. 
Bleeding from right ear, nose and mouth. Pupils very small, but equal; 
do not react to light. Reflexes — knee-jerks diminished but equal ; no ankle 
clonus nor Babinski ; abdominal reflexes absent. Fundi negative except for 
a general retinal suffusion and congestion. 

Treatment. — Expectant palliative ; shock treatment instituted. 

Examination (16 hours after admission). — Temperature, 100.2°; pulse, 
84; respiration, 22; blood-pressure, 138. Conscious but very stuporous. 
Straw-colored fluid oozing from right ear; right mastoid area ecchymosed 
and boggy. Pupils — both pin-point (no morphia has been administered). 
Reflexes — knee-jerks active but equal; suggestive Babinski and Gordon 
reflexes but no ankle clonus ; abdominal reflexes present and equal. Fundi 
cannot be accurately observed on account of the small pupils. Lumbar 
puncture — bloody cerebrospinal fluid and under a pressure of 11 mm. 
X-ray (Doctor W. H. Stewart) — "fracture of right squamous bone extend- 
ing down into right petrous bone. ' ' 

Treatment. — Expectant palliative continued. (The operation of sub- 
temporal decompression and drainage should have been performed at 
this time.) 

Examination (36 hours after admission). — Temperature, 100°; pulse, 
78 ; respiration, 18 ; blood-pressure, 140. Conscious ; complaining of severe 
headache — "splitting." Discharge of cerebrospinal fluid from right ear 
has ceased ; otoscopic examination reveals a small tear in the lower posterior 
quadrant of the right tympanic membrane ; left ear-drum of normal appear- 
ance. Hearing of right ear definitely impaired — cannot hear watch. Slight 
weakness of right side of face — peripheral type. Pupils not so small; 
equal, and react well. Reflexes — left knee-jerks possibly more active than 
right ; still suggestive bilateral Babinski ; no ankle clonus ; abdominal re- 
flexes — present and equal. Fundi — retinal vessels dilated; nasal halves of 
the optic disks blurred — right more than left. Lumbar puncture — cerebro- 
spinal fluid bloody and under an increased pressure of approximately 14 mm. 

Treatment. — Expectant palliative. A decompression operation should 
certainly have been advised at this time, but unfortunately it was not 



ACUTE BRAIN INJURIES 221 

considered necessary in the belief that repeated lumbar punctures and 
drainage of 15-20 c.c. of cerebrospinal fluid each time would be sufficient. 
This was performed daily upon 4 consecutive days ; each time the cerebro- 
spinal fluid was bloody and under a pressure of approximately 12-14 mm. ; 
patient felt better after each lumbar puncture — particularly a lessening 
of the headache. 

Examination at discharge (12 days after admission). — Temperature, 
99.4° ; pulse, 80 ; respiration, 18 ; blood-pressure, 142. Patient very irri- 
table, restless and complains of ' ' shooting headache. ' ' He disobeys orders, 
will not remain in bed, and insists upon going home, because "you are 
starving me and I can't sleep here." Patient is discharged at his own 
risk (A. 0. R.). Right mastoid area still slightly ecchymosed and tender 
upon palpation. Weakness of right side of face not elicited by special tests. 
Pupils rather small but equal, and react well. Reflexes very active but 
equal ; no Babinski nor ankle clonus ; abdominal reflexes present and equal. 
Fundi — retinal vessels still enlarged ■ edematous blurring of the nasal mar- 
gins of both optic disks persists. Patient refused another lumbar puncture 
at this time and said ' • I won 't be cut up. ' ' 

Treatment. — Relatives advised to keep patient home in bed quietly and 
on soft diet; daily catharsis and no alcohol. 

Examination (September 10, 1916 — 4 months after injury). — Patient 
has tried to work but had to "give up" each time. "Too much pain in 
my head and dizzy spells." "Just dead at night." Pupils equal and react 
normally. Reflexes active but equal ; no ankle clonus nor Babinski. Fundi 
- — general congestion of entire retinae ; distinct obscuration of the nasal mar- 
gins of both optic disks. Patient refused a lumbar puncture. 

Examination (October 20, 1917 — 17 months after injury). — Patient 
complains of headache and "general tiredness"; is a night watchman 
"where I can sit and sometimes sleep." Pupils negative. Reflexes active 
but otherwise negative. Fundi — retinal veins still large ; the nasal margins 
of both optic disks obscured by edema. 

Last Examination (August 12, 1918 — 27 months after injury). — Still 
complains of headache — particularly in the morning. "Never really well." 
Brother says he has become a "bum." Pupils negative. Reflexes active 
but otherwise negative. Fundi — blurring of the nasal margins still persists. 
Patient advised again to enter hospital for observation, but he has not 
consented to do so. 

Remarks. — The end-result of this patient will apparently be most dis- 
couraging — becoming more and more unstable emotionally, definitely im- 
paired mentally, and it will not be surprising if institutional care will 
eventually be advisable. An early subtemporal decompression and drainage. 
unilateral, and if necessary, bilateral, should have been performed, but the 
relatives were so influenced by the patient himself, who was not in a normal 
mental condition at the time following the injury, so that the operative 
permission requested could not be obtained. 

The delayed weakness of the right side of the face which was not ascer- 
tained until 36 hours after the injury would point merely to an edema of 
the facial nerve itself within the aqueduct of Fallopius; it was only of tern- 



222 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

porary duration in that no signs of its presence could be elicited at the time 
of the patient's discharge, ten days later. 

The pupillary contraction, which persisted for more than 36 hours fol- 
lowing the injury, was undoubtedly due to a bilateral cortical irritation — 
most probably a subarachnoid hemorrhage and not of sufficient size and com- 
pression to produce the paralytic enlargement of the pupils ; in some patients, 
the initial shock is so great that the pupils are dilated even in the presence 
of a great increase of the cortical irritability, but as soon as the shock 
lessens then the pupils become contracted, and if the cortical irritation be- 
comes greater and greater until a definite supracortical clot and compression 
occur, then the pupils gradually enlarge to the point of dilatation and no 
longer react to light unless sluggishly; a definite inequality in the size of 
the pupils — such as a very much contracted pupil of ipsolateral cortical 
irritation or a dilated pupil of ipsolateral cortical compression, can be of 
great value in the localization of the greater lesion of either hemisphere. 

Case 34. — Acute fracture of base of skull ; signs of a marked increase of 
intracranial pressure. No operation. Doubtful recovery. 

No. 814. — Vincent. Twenty-four years. White. Single. Clerk. Canada. 

Admitted March 22, 1917, Polyclinic Hospital. 

Discharged April 25, 1917 — 32 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient tripped over a rug, falling headforemost into 
fireplace and striking the back of his head against an andiron; immediate 
loss of consciousness ; brought to hospital in ambulance. 

Examination upon admission (80 minutes after injury). — Tempera- 
ture, 97°; pulse, 60; respiration, 16; blood-pressure, 128. Unconscious; 
cold, clammy skin and temperature of 97, indicating severe shock (in the 
presence of a subtentorial injury affecting the medulla and thus retarding the 
pulse- and respiration-rates) . Laceration of two inches long over left occipi- 
tal area. Profuse hemorrhage and discharge of cerebrospinal fluid from left 
ear ; left mastoid ecchymosis and bogginess. Pupils slightly dilated but equal ; 
reaction to light sluggish. Reflexes — knee-jerks equally exaggerated ; double 
ankle clonus and double Babinski ; abdominal reflexes absent. Fundi — reti- 
nal veins dilated; optic disks clear. 

Treatment. — Expectant palliative ; vigorous treatment of shock instituted 
and careful observation. 

Examination (10 hours after admission). — Temperature, 98.8°; pulse, 
64; respiration, 20; blood-pressure, 132. Semiconscious; exceedingly rest- 
less, requiring morphia and restraint. Discharge of blood and cerebrospinal 
fluid from left ear not so profuse. Pupils equal and react more actively. 
Reflexes — knee-jerks exaggerated ; bilateral ankle clonus and Babinski per- 
sist ; abdominal reflexes, however, can be obtained with difficulty. Fundi — 
retinal veins dilated; distinct edematous blurring along the lower nasal 
quadrants of both optic disks. Lumbar puncture — cerebrospinal fluid 
bloody and under increased pressure (12 mm.). X-ray (Doctor G. W. 
Welton) — "unusually distinct lamboidal suture, and particularly on the 
left side, as though a diastasis of it had occurred. ' ' 



ACUTE BRAIN INJURIES 223 

Treatment. — Expectant palliative continued. (If an operation to re- 
lieve this increased pressure and to drain the intracranial hemorrhage were 
to be advised, this was the time it should have been performed. It was 
thought, however, that the intracranial pressure was not sufficiently high 
to advise an operation in the belief that the normal absorption would ' ' take 
care of ; ' this condition ; the subsequent history, however, makes me feel that 
an operation at this time would have been the proper procedure — at least it 
would have given him a chance for a greater ultimate improvement. ) 

Examination (36 hours after injury). — Temperature, 99.8°; pulse, 66; 
respiration, 20; blood-pressure, 134. Conscious, but confused mentally; 
wants to go home — requiring restraint and morphia. Bleeding from left ear 
has ceased; otoscopic examination reveals an extensive laceration of the 
entire posterior attachment of left tympanic membrane to the bone ; a dark 
currant-jelly clot is observed extruding through the tear; left mastoid 
area very much swollen, ecchymotic and extremely tender. Pupils equal 
and react normally. Reflexes — both knee-jerks exaggerated; exhaustible 
ankle clonus and only a suggestive bilateral Babinski ; abdominal reflexes 
present and equal. Fundi — nasal half of left optic disk obscured, but only 
nasal margin of right optic disk blurred ; retinal veins engorged and tortuous. 

Treatment. — Expectant palliative continued. 

Examination (6 days after admission). — Temperature, 99.4° ; pulse, 68; 
respiration, 20 ; blood-pressure, 132. Perfectly conscious ; complains of 
severe headache, more on left side. Laceration of scalp healing per primam. 
Reflexes very much exaggerated but neither ankle clonus nor Babinski can 
be elicited. Fundi — nasal margins of both optic disks obliterated by edema ; 
retinal veins dilated and tortuous. 

Examination at discharge (32 days after admission). — Temperature,. 
98.8°; pulse, 66; respiration, 20; blood-pressure, 138. Conscious; slight 
general headache each day but not severe ; ' ' sort of weak all over. ' ' Lacera- 
tion of scalp healed. Hearing of left ear impaired — bone conduction being- 
greater than air conduction and therefore left middle ear involvement. 
Pupils equal and react normally. Reflexes very active but otherwise nega- 
tive. Fundi — retinal veins still enlarged ; nasal margins of both optic disks 
indistinct — left more than right. 

Report (by letter, May 15, 1917, 2 months after injury). — "Doing 
well except daily headaches, very irritable and wants to sleep most of the 
time ; is not interested in things as before the injury. ' ' 

Report (by letter, September 21, 1917, 6 months after injury). — "My 
condition is a little improved, but far from being myself; headache almost 
all the time and so light-headed ; I have lived up to your diet and 
instructions. ' ' 

Last report (by letter, August 12, 1918, 17 months after injury). — "Vin- 
cent has never been himself since the accident. Before, he was a hard- 
working, cheerful boy; now, he complains of his head every day, grumbles 
at everything, very irritable, and must lie down after any exertion on account 
of 'pain in my head.' He cannot work and T do not know what to do with 
him. Would an operation help him now?" 

Remarks. — The above question of the mother is a very pertinent one. and 



224 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

yet it is doubtful whether an operation at this time would improve his con- 
dition. Naturally, a thorough examination would be necessary to ascertain 
the presence or not of an increased intracranial pressure ; if present, then a 
decompression would give him a definite chance of being improved — particu- 
larly the headache relieved and his general condition so improved that it 
would be possible for him to return to his work. On the other hand, if no 
increased intracranial pressure was present, then no operation would be 
indicated and there would be nothing to be done except the expectant 
palliative treatment that he is now receiving. These are the patients for 
whom an operation at the time of the injury might have effected a greater 
ultimate recovery. 

This patient made such an excellent immediate recovery as far as life 
and his general condition were concerned that, upon the hospital chart, he 
could have been designated as ' ' Well ' ' ; and yet upon following his history for 
a period of almost one year and a half, we find that he is not welL and it is 
very doubtful if he will ever enjoy his former good health. Considering the 
ultimate recovery of these patients, and chiefly the emotional and mental 
status, it is then that we are impressed by the advisability and the necessity 
of an early and efficient relief of the increased intracranial pressure as soon 
as the signs of shock have subsided. It is taking too great a "chance" to 
permit these patients to absorb the cerebral edema, unless the signs of 
intracranial pressure are mild, and only these "mild" cases should be treated 
by the expectant palliative method. 

Recent Mild Brain Injuries Associated with a Depressed Fracture of 
the Vault, with and without a Fracture of the Base of the Skull 

A cranial injury of sufficient force to produce a fracture of the vault of 
the skull so that the line of fracture radiates from the area of contact, usually 
causes the line or lines of fracture to extend to the base of the skull — 
the weaker portions, and particularly the middle fossa; in this manner, 
extensive linear and also depressed fractures of the vault are frequently 
associated with a fracture of the base of the skull. 

All depressed fractures of the vault (with almost no exceptions) should 
be elevated or removed — and as early as possible after the initial shock of the 
injury has subsided ; if, however, there are present definite signs of a marked 
increase of the intracranial pressure due either to hemorrhage or cerebral 
edema and in the presence or absence of a fracture of the base of the skull, 
then it is better surgical judgment and of much less risk to the patient to 
perform first, a subtemporal decompression on the same side of the head as 
the depressed area of bone, arid then, at the same operation, to elevate or 
remove the depressed area of bone. If this method is not followed in patients 
having a high intracranial pressure, then the elevation and removal of the 
bony depression of the vault is attended with much danger of damage to 
the underlying cerebral cortex — and especially if the dura has been torn; 
the cerebral tissue may be protruded and even extruded into the bony open- 
ing and thus a permanent impairment, anatomically and clinically, will 
result from the damage to this more highly developed portion of the cerebral 
cortex ; if adjacent to the motor areas, then the impairment of paralysis will 



ACUTE BRAIN INJURIES 225 

not be easily overlooked. The history of many of these patients who have 
undergone this incomplete and improper method of surgical relief is that 
their condition is worse after the operation than before it — and it has been 
a correct observation; so much so, that it has been advocated that no de- 
pressed fracture of the vault should be elevated or removed unless definite 
signs of impairment to the underlying cerebral cortex should appear later — 
and then the operation at that late date. This latter method of expectancy 
would be the safer treatment to follow in many patients having a high 
intracranial pressure as compared with the method of attempting only to 
elevate or remove the depressed area of bone which is frequently associated 
with much damage to the underlying cerebral tissues, but the most rational 
and successful method of treatment for these patients is the relief first of 
the general increase of the intracranial pressure by means of a subtemporal 
decompression and then the elevation or removal of the depressed area of 
the vault ; in this manner, the general intracranial pressure is lowered over 
a comparatively silent area of the cerebral cortex, the dura opened and 
permitted to remain open, and the operative incision can be firmly closed 
by the temporal muscle so that there is no danger of unsightly and serious 
complications of cerebral herniae and fungi. 

Naturally, in patients having a depressed fracture of the vault with and 
without a fracture of the base and not associated with a marked increased 
intracranial pressure — these patients require only the elevation or removal 
of the depressed area of bone with and without the opening of the under- 
lying dura, according to the pathology there ascertained ; also, in the doubt- 
ful cases of high intracranial pressure before operation, when the underlying 
dura at the site of bony depression is found to be exceedingly tense and 
bulging and the intracranial pressure is therefore much higher than was 
ascertained before the operation, then it is better surgical judgment not to 
open the dura, but to perform an ipsolateral subtemporal decompression 
immediately, and then, if advisable on account of an underlying local lesion, 
the dura beneath the depressed area of bone may now be safely opened. 

If this method of conservative surgical treatment of these patients having 
depressed areas of the vault is not used, then not only is the immediate dan- 
ger present of making the condition of the patient worse than before the op- 
eration, but the remote effects upon the underlying cerebral cortex adjacent 
to the former bony depression are very probable in the formation of adhesions 
in the presence of an unrelieved increased intracranial pressure, and thus 
the great danger of future cortical irritation producing headache, epilep- 
tiform seizures, changes of personality, and even a mental derangement 
itself. Merely to elevate or remove a depressed area of the vault in the 
presence of a high intracranial pressure is not only meddlesome surgery 
but a very dangerous procedure, both in the immediate effects and in the 
remote results. 

Recent fractures of the base of skull associated with depressed fractures 
of the vault. Two operations. 

A. Intracranial pressure mild; therefore removal of depressed area of 
bone first, and then a subtemporal decoiuprcssiou was considered advisable. 
Excellent recovery. 
15 



226 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 35. — Acute fracture of base associated with a depressed fracture 
of the vault of the skull ; mild sigus of au increased intracranial pressure. 
Two operations — removal of depressed area of bone first, then a subtemporal 
decompression. Excellent recovery. 

No. 057. — August. Thirty-nine years. White. Married. Carpenter. 
Austria. 

Admitted April 21, 1913, Polyclinic Hospital. Referred by Doctor 
J. A. Bodine. 

Operations April 21, 1913 — 8 hours after injury. First, removal of 
depressed area of vault; second, left subtemporal decompression. 

Discharged May 6, 1913 — 15 days after injury and operations. 

Family history negative. 

Personal history negative. 

Present Illness — While working in a new building, patient was struck 
upon the top of head by a large iron door ; loss of consciousness for several 
minutes ; brought to the hospital in the ambulance. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 99.4° ; pulse, 64 ; respiration, 18 ; blood-pressure, 160. Strong muscu- 
lar man. Semiconscious ; replies to questions drowsily and irrelevantly in 
German. Definite depression of anterior portion of left parietal bone. 
Bleeding and discharge of cerebrospinal fluid from left ear; definite left 
mastoid ecchymosis ; left orbital ecchymosis and left subconjunctival hemor- 
rhage. Pupils — left pupil larger than right; reaction to light sluggish. 
Reflexes — knee-jerks active, right greater than left ; no ankle clonus, but 
right Babinski ; right abdominal reflexes less active than left. Fundi — 
retinal veins enlarged ; distinct haziness and blurring edema of the nasal 
halves of both optic disks. Lumbar puncture — cerebrospinal fluid blood- 
tinged at first, then clear and under an increased pressure (approximately 
14 mm.). 

Treatment. — No shock being present and the definite signs of a local 
cerebral impairment and an increase of the intracranial pressure being 
ascertained, the operative removal of the depressed area of bone advised 
as early as possible; (at the time, no further operation was considered 
necessary nor advisable). 

Operations (8 hours after admission). — 1st. Removal of depressed area 
of bone : curvilinear incision of 2 1 / 2 inches over anterior portion of left 
parietal bone ; small trephine opening made at posterior and upper margin 
of depressed area ; opening enlarged by rongeurs to a diameter of 1% inches. 
Dura bluish and under high tension ; it was not considered advisable to open 
dura through this small bony opening for fear that the increased intra- 
cranial pressure would damage the underlying cortex, so that a homolateral 
(left) subtemporal decompression was thought necessary. 

2nd. Left subtemporal decompression : usual incision, bone removed and 
no complications. Dura tense and bluish; upon incising it, much blood- 
tinged cerebrospinal fluid escaped under pressure; numerous small blood- 
clots — size of ten-cent pieces, welled out of opening and apparently coming 
from base of the skull. Cortex congested but otherwise negative; pulsation 



ACUTE BRAIN INJURIES 



227 



normal at close of operation. Usual closure with 2 drains of rubber tissue 
inserted. Duration of operations, 75 minutes. 

Post-operative Notes. — Uneventful operative recovery ; general condition 
improved immediately. 

Examination at discharge (15 days after admission). — Temperature, 
98.6° ; pulse, 74 ; respiration, 22 ; blood-pressure, 152. No complaints, except 
for soreness over left side of head. Both operative incisions have healed 
perfectly; decompression site bulges slightly, pulsates normally. Hearing 
of left ear impaired ; bone conduction greater than air conduction. Reflexes 
very active but otherwise negative. Fundi — retinal veins slightly enlarged ; 
indistinct blurring of lower nasal quadrants of both optic disks ; physiologi- 
cal cup shallow from edema 
and possibly new tissue for- [ 
mation. X-ray demonstrates 
the area of bony defect of the 
left vault due to the two 
operations (Fig. 62). 

Examination ( September 
21, 1915—29 months after in- 
jury) . — No complaints ; 
works daily. Hearing of lett 
ear less acute than right; 
bone conduction equals air 
conduction. Reflexes nega- 
tive. Fundi negative. 

Last Examination (May 
10, 1918—61 months after in- 
jury) . — Examination was 
made at Fort Jay, New 
York, as patient had just 
been interned as an enemy 
alien. No complaints; both 
operative sites depressed and 
neither pulsates (due most 
probably to new bone for- 
mation). Hearing of left ear equals acuity of hearing of right ear: tuning 
fork tests not made, unfortunately. Reflexes negative. Fundi negative. 

Remarks.— The operative treatment of this type of patient is now just 
the reverse; that is, patients having depressed fractures of the vault, 
with or without a fracture of the base of the skull, and there are defi- 
nite signs of an increased intracranial pressure, then it is always better 
surgical judgment to perform the subtemporal decompression first and thus 
relieve whatever increased intracranial pressure there is, and then at the 
same operation, remove the depressed area of the vault or at least elevate it ; 
in this manner, the danger of operative damage resulting to the cerebral 
cortex underlying the depressed fracture of the skull is practically nil and 
the lessening of the increased intracranial pressure of subdural and sub- 
arachnoid hemorrhage, together with the cortical irritation of the depressed 




Fig. 62. — Extensive bony defect of left parieto-squamous 
area of the vault following an operative removal of the bone 
and a lowering of the increased intracranial pressure. 
Excellent recovery. 



228 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

area of bone is thus secured. To open the dura underlying the depressed 
fracture of the vault, and there is a definite increase of the intradural pres- 
sure, then there is a great risk of the underlying cerebral cortex being 
damaged by its protrusion upward into the overlying dural and bony open- 
ing and definite clinical symptoms and signs of this cortical impairment being 
exhibited by the patient later ; the danger, too, of convulsive seizures is also 
increased, especially in the presence of an increased intracranial pressure. 

Case 36. — Acute fracture of base associated with depressed fracture of 
vault of skull ; mild signs of an increased intracranial pressure. Two oper- 
ations — removal of depressed area first, and then a subtemporal decom- 
pression. Excellent recovery. 

No. 058. — Constantino. Fifty-three years. White. Married. Laborer. 
Italy. 

Admitted Apri] 23, 1913, Polyclinic Hospital. Referred by Doctor 
J. A. Bodine. 

Operations April 23, 1913 — 4 hours after injury. First, removal of 
depressed area of bone ; second, right subtemporal decompression. 

Discharged May 7, 1913 — 14 days after injury and operations. 

Family history negative. 

Personal history negative. 

Present Illness. — While working in a new building, patient fell a distance 
of 3 stories, striking upon the top of his head ; immediate loss of conscious- 
ness ; brought to the hospital in the ambulance. 

Examination upon admission (10 minutes after injury). — Tempera- 
ture, 99.4° ; pulse, 84; respiration, 20; blood-pressure, 156. Well-developed 
and nourished. Patient had regained consciousness in the ambulance and 
refused to go to bed in the ward — walking about and desiring* to go home. 
Distinct depression of left parietal bone adjacent to the longitudinal sinus. 
Bleeding and discharge of cerebrospinal fluid from right ear ; right mastoid 
ecchymosis. Pupils — right larger than left and reacts to light sluggishly. 
Reflexes — knee-jerks exaggerated, left more than right; suggestive left 
Babinski ; left abdominal reflexes possibly depressed. Fundi — retinal veins 
enlarged — possibly more in right than in left ; nasal margins and nasal 
halves of optic disks obscured by edema. Lumbar puncture — cerebrospinal 
fluid blood-tinged and under an increased pressure (approximately 13 mm.) . 

Treatment. — The rapid onset of the marked signs of an increased intra- 
cranial pressure (it being rare for definite signs of an increased intracranial 
pressure to appear within 6 hours after a cranial injury due undoubtedly 
to the usual association with severe shock and to a less rapid formation of 
cerebral edema and intracranial hemorrhage) made advisable the immediate 
removal of the depressed area of bone, and if the intracranial pressure was 
confirmed to be markedly increased, then a subtemporal decompression and 
drainage would be indicated — and on the right side on account of the 
neurological examination indicating a greater impairment of the right 
cerebral hemisphere. 

Operations (4 hours after admission). — 1st. Removal of depressed area 
of vault: through a curvilinear incision of 2 inches overlying the de- 
pressed area of the upper portion of left parietal bone (just to the left 



ACUTE BRAIN INJURIES 229 

of the longitudinal sinus), a small trephine opening was made posterior to 
the depressed fracture; upon removing the small button of bone, a dark 
currant jelly clot was forced out under very high tension. For fear that 
the underlying dura had also been torn, it was now thought advisable 
to perform a right subtemporal decompression to lessen the intracranial 
pressure and then to remove or elevate the depression. A cotton pad was 
accordingly placed over the trephine opening to prevent the protrusion of 
more clot and possibly brain tissue (a most dangerous complication for fear 
of producing paralysis and other signs of cortical destruction) and a right 
subtemporal decompression was hurriedly performed. 

2nd. Right subtemporal decompression: Usual incision, bone removed 
and no complications. An extradural currant jelly clot had extended down- 
ward to about the middle of the decompression opening ; this was removed. 
Dura tense and slightly bluish ; upon incising it blood-tinged cerebrospinal 
fluid welled out under increased pressure ; no distinct subdural clots evac- 
uated. Cortex "wet" and edematous, showing the characteristic arachnoid 
"sweating." Usual closure with 2 drains of rubber tissue inserted. Attempt 
was now made to elevate the depressed area of bone, but as the line of frac- 
ture extended beyond the longitudinal sinus and as the longitudinal sinus 
itself was found to be torn and still bleeding profusely, it was considered 
advisable merely to rongeur away more of the depressed area of bone and 
then to pack the longitudinal sinus; this was done with 2 small strips of 
gauze packing which were left in situ. Usual closure with 2 drains of 
rubber tissue inserted. Duration of both operations, 80 minutes. 

Post-operative Notes. — Uneventful operative recovery; the gauze strips 
packing the longitudinal sinus were removed in 48 hours and no bleeding 
occurred; general condition gradually improved. 

Examination at discharge (14 days after admission). — Temperature, 
99° ; pulse, 76; respiration, 22; blood-pressure, 146. No complaints except 
for a feeling of fulness, especially over right side of head and impairment 
of hearing of right ear; otoscopic examination reveals a small tear in the 
lower posterior portion of the right tympanic membrane — apparently clos- 
ing; bone conduction greater than air conduction in right ear. Pupils 
equal and react normally. Reflexes active but otherwise negative. Fundi — 
enlargement of retinal veins persists ; a slight blurring of the nasal margins, 
especially of the right optic disk. X-ray (Doctor A. J. Quimby) — "bony 
defects due to removal of depressed bone at vertex and to right decompres- 
sion operation, demonstrated" (Fig. 63). 

Examination (October 20, 1915 — 30 months after injury). — Xo com- 
plaints; returned to work 6 weeks after injury and has been working daily 
since. Reflexes negative. Fundi negative. Superficial examination reveals 
no impairment of hearing of right ear. 

Last Examination (July 14, 1918 — 63 months after injury V — Xo com- 
plaints referable to the head injury. Hearing negative: air conduc- 
tion greater than bone conduction of both ears. Reflexes negative. 
Fundi negative. 

Remarks. — This is another patient upon whom it would have been better 
surgical judgment to have performed a right subtemporal decompression 



2 3 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



first, and then the removal or elevation of the vault — and in reality, this 
order of procedure was used with the exception of the trephine opening at 
the site of the depression. In the period when this operation was performed 
(1913), it was not known that the ophthalmoscopic and lumbar puncture 
examinations could be such accurate indications of increased intracranial 
pressure as they are now known to be, so that similar patients to this one 
would now always have the increased intracranial pressure lessened, first by 

a subtemporal decompres- 
^ sion, and then the depressed 

area of the vault treated 
accordingly. If this method 
of procedure is not used, then 
there are certain patients 
with high intradural pres- 
sure who will be permanently 
damaged by the operative 
3ortical impairment resulting 
from the local cortical ex- 
trusion at the site of the de- 
pressed area of the vault and 
through the open dura 
underlying it. 

It was very interesting 
in this patient following the 
operation to observe the 
rapid subsidence of the signs 
pointing to a lesion of the 
right hemisphere : enlarged 
right pupil resulting from 
the paralytic effect of com- 
pression upon the right cor- 
tex, the exaggerated left deep 
reflexes, suggestive left Ba- 
binski and the depressed left 
abdominal reflexes, while the 
signs of pressure as exhibited 
by the retinal veins were greater in the right fundus than in the left; the 
escape of blood and cerebrospinal fluid from the right ear is of little signifi- 
cance regarding the intracranial condition of the increased pressure which 
is all-important in these patients. The rapid improvement in the general 
condition of this patient and the almost immediate disappearance of the 
symptoms and signs of an increased, intracranial pressure following the 
operations were most impressive. 

Case 37. — Acute fracture of base associated with a depressed fracture 
of vaults definite signs of a mild increase of the intracranial pressure. Two 
operations — removal of the depressed area of bone first, and then a sub- 
temporal decompression. Excellent recovery. 




Fig. 63. — Irregular bony defect of left parietal bone following 
the removal of bony depression; the increased intracranial 
pressure lowered by a right subtemporal decompression. 
Excellent recovery. 



ACUTE BRAIN INJURIES 231 

No. 145. — Annie. Forty years. White. Married. Housework. U. S. 

Admitted April 9, 1914, Polyclinic Hospital. Referred by Doctor 
C. H. Chetwood. 

Operations. — April 9, 1914 — two hours after injury. First, removal of 
depressed area of vault ; second, left subtemporal decompression. 

Discharged April 20, 1914 — ten days after injury and operations. 

Family history negative. 

Personal history negative. 

Present Illness. — While at home, patient slipped and fell headlong 
down a flight of stairs ; apparently no loss of consciousness ; brought to hos- 
pital in the ambulance. 

Examination upon admission (one hour after injury). — Temperature, 
98.6°; pulse, 90; respiration, 20; blood-pressure, 140. Perfectly conscious 
and clear mentally ; odor of alcohol upon her breath, but not to the degree 
of intoxication. Extensive laceration of scalp of 3 inches parallel and just 
to the left of the longitudinal sinus and immediately posterior to the frontal 
hairline ; bleeding profusely and matted with hair ; careful probing reveals 
a depressed fracture of the underlying bone ; dark clots and particles of 
brain tissue protruding through opening. Profuse bleeding from left ear ; 
left mastoid ecchymosis. Pupils equal and react normally. Reflexes : knee- 
jerks active — right possibly greater than left; no ankle clonus nor Ba- 
binski. Fundi negative. 

Treatment. — Patient insisted that nothing was the trouble with her and 
desired to return home ; one hour later, in the ward, she complained of being 
dizzy and having a headache ; then became drowsy and stuporous. An im- 
mediate removal of the depressed area of bone was considered advisable. 

Operations (90 minutes after admission). — First, removal of depressed 
area of left parietal bone : scalp laceration enlarged at each end downward, 
thus making a sort of curvilinear flap incision ; a depressed fracture just 
to the left of the superior longitudinal sinus disclosed to be depressed to a. 
depth of one-half inch about which dark blood clots and brain tissue ooze. 
Small trephine opening made at the lower outer edge of the depression and 
surrounding depressed bone rongeured away — exposing a large extradural 
clot the size of a lemon; through the underlying torn dura, small subdural 
clots extruded. Profuse bleeding occurred due to a tear of the longitudinal 
sinus which was packed successfully by a small gauze tape packing. Usual 
closure with 3 drains of rubber tissue inserted. On account of the defi- 
nite increase of intracranial pressure as shown by the extrusion of brain 
tissue through the torn dural opening, an immediate homolateral (left") de- 
compression was considered advisable. 

Second, left subtemporal decompression: usual incision, bone removed 
and no complications. Dura tense and bluish ; upon incising it almost pure 
blood spurted a height of 8 inches for 18 seconds: upon enlarging dural 
opening, subdural clots, the size of silver dimes, welled ont of opening. 
Cortex congested, otherwise apparently normal. Usual closure with 2 
drains of rubber tissue inserted. Duration of operation, 80 minutes. Post- 
operative notes: uneventful operative recovery: general condition 
promptly improved. 



232 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Examination at discharge (10 days after admission). — Temperature, 
98.6° ; pulse, 78; respiration, 20; blood-pressure, 132. No complaints other 
than soreness over left side of head. Both operative incisions have healed 
nicely. Hearing of left ear impaired ; otoscopic examination of left ear re- 
veals a large laceration of the entire posterior portion of left tympanic mem- 
brane ; bone conduction is greater than air conduction in left ear. Pupils 
equal and react normally. Reflexes active but otherwise negative. Fundi — 
retinal veins slightly enlarged ; no definite blurring of the optic disk margins. 
Decompression area moderately tense. X-ray (Dr. A. J. Quimby) — "bony 

defects of left subtemporal 
\ "~i decompression and removal 

of depressed area of bone 
clearly shown" (Fig. 64). 

Examination (September 
20, 1916— 29 months after in- 
jury). — No complaints re- 
ferable to head injury; 
patient, however, is becoming 
alcoholic — similar to her two 
sisters and one brother. 
"Never felt better in my 
life." Hearing of left ear 
%|JjHfl less acute than right; bone 

conduction equals air con- 
duction. Reflexes difficult to 
obtain but otherwise nega- 
tive. Fundi — both retinae 
congested but otherwise 
negative. 

Fig. 64.-Oval bony defect of left subtemporal decom- Last Examination (June 

pression and irregular bony defect of the removal of the depressed (\ 1 Q1 8 ^0 mrvnfh« nftpv 

area of left parietal bone demonstrated; an unusual number of "' . inuiiiiib tt-Liei 

silver clips clearly shown in the area of decompression. Excellent j. n j U r y ) . No Complaints * 

patient is no longer drink- 
ing, having become a member of a temperance organization and also a 
suffragette interested in ward politics. "lam now a good Tammany 
man." Hearing— no impairment elicited. Reflexes sluggish but otherwise 
negative. Fundi negative. 

Remarks. — It is indeed surprising that a person with such a severe 
cranial condition could walk about in the hospital ward with practically 
no complaints; it should be remembered, however, that a sort of natural 
decompression had been performed by the injury itself, so that through the 
depressed area of the vault the blood clots and even brain tissue could 
escape, thus relieving the intracranial pressure ; to be sure, such a decom- 
pression by allowing brain tissue to be extruded is a poor means of lessen- 
ing the intracranial pressure — the end-result being most disastrous, even 
if the patient should survive. In all probability, however, the patient would 
soon have gone into a condition of coma due to the continued hemorrhage 
and cerebral edema and the rising intracranial pressure resulting from the 



m 



ACUTE BRAIN INJURIES 233 

insufficient drainage, and then the prognosis would have been very 
grave indeed. 

B. Intracranial pressure very high; therefore, subtemporal decom- 
pression first, followed by a removal of depressed area of bone. Ex- 
cellent recovery. 

Case 38. — Acute fracture of base of skull associated with a depressed frac- 
ture of vault; marked signs of an increased intracranial pressure. Two 
operations — subtemporal decompression first, then removal of depressed area 
of bone. Excellent recovery. 

No. 075. — Martin. Twenty-two years. White. Single. Iron-worker. 
United States. 

Admitted August 11, 1913, Polyclinic Hospital. Referred by Doctor 
John P. Grant. 

Operations (August 11, 1913 — 5% hours after injury) . — First, right sub- 
temporal decompression ; second, removal of depressed area of bone. 

Discharged August 24, 1913 — 13 days after injury and operations. 

Family history negative. 

Personal history negative. 

Present Illness. — While walking along the street, patient was struck 
upon the head by an iron bar which had fallen from a chimney of 5 
stories high ; immediate loss of consciousness ; brought to the hospital in 
the ambulance. 

Examination upon admission (30 minutes after injury). — Tempera- 
ture, 98.8° ; pulse, 72; respiration, 22; blood-pressure, 128. Well-developed 
and nourished youth. Unconscious but not in severe shock. Deep irregular 
laceration over right frontal bone extending beyond the median line ; gentle 
probing reveals a distinct fracture of the underlying bone. Profuse bleed- 
ing and discharge of cerebrospinal fluid from right ear; extensive right 
mastoid ecchymosis. Pupils equal and react normally. Reflexes — knee- 
jerks can just be obtained and are equal; tendency to left Babinski; left 
abdominal reflex absent, whereas right reflex can just be obtained. Fundi — 
marked dilatation of retinal veins; distinct edematous blurring of nasal 
halves of both optic disks. (No lumbar puncture performed as the signs 
of high intracranial pressure were present in both fundi and the discharge 
of bloody cerebrospinal fluid from the right ear indicated that an intra- 
cranial hemorrhage had occurred ; at present, a lumbar puncture would be 
performed to estimate accurately the intracranial pressure by means of the 
spinal mercurial manometer.) X-ray (Doctor A.J.Quimby') — "small irregu- 
lar depressed fracture of median portion of frontal bone" (Fig. 65). 

Treatment. — As the patient was in excellent condition and did not show 
the usual signs of shock, an immediate operation was advised to lower this 
increased intracranial pressure and to remove the depressed bone. 

Operations (5 hours after admission). — 1st. Right subtemporal decom- 
pression (as the intracranial pressure was high it was thought advisable 
first to perform the decompression, and then to remove the depressed area 
of bone) : usual vertical incision, separation of fibres of the underlying 
temporal muscle, and removal of bone to a diameter of 2} 2 inches. Dura 
very tense and slightly bluish; upon incising it, bloody cerebrospinal fluid 



234 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



spurted to a" height of 3 inches. Cortex very congested and edematous — 
much bloody cerebrospinal fluid escaping so that the brain pulsated normally 
at the end of the operation. Usual closure with 2 drains of rubber 
tissue inserted. 

2nd. Removal of depressed area of bone: laceration of right frontal 
area enlarged at each end and retractors inserted exposing a depressed frac- 
ture of the right frontal bone extending over the longitudinal sinus and about 
one-half inch beyond the midline ; a small trephine opening made at its lower 
portion and then the depressed area of bone rongeured upward to the 

longitudinal sinus, but not 
beyond, as it was not consid- 
ered necessary. There was 
no tear of the underlying 
dura nor had the longitu- 
dinal sinus been torn. 
Usual closure of scalp with 
2 drains of rubber tissue in- 
serted. Duration of both 
operations, 70 minutes. 

Post-operative Notes. — 
Uneventful operative recov- 
ery; immediate general im- 
provement. 

Examination at discharge 
(13 days after admission). — 
Temperature, 98.8° ; pulse, 
78 ; respiration, 22 ; blood- 
pressure, 134. No com- 
plaints except for soreness 
over right side of head ; gen- 
eral weakness but otherwise 
"feels fine." Laceration of 
scalp and decompression in- 

Fig. 65.— Depressed fracture of median portion of frontal cision have healed; site of 
tone associated with a high intracranial pressure; therefore -, • , • 

a right subtemporal decompression first, to be followed by decompression Operation 

fen'^covery.' 116 depressed area ° f ** fr ° ntal b ° ne ' Excel " bulges slightly and pulsates. 

Impairment of hearing of 
right ear — bone conduction being greater than air conduction; otoscopic 
examination reveals a small perforation of the posterior portion of right 
tympanic membrane; a slight right mastoid ecchymosis persists. Pupils 
equal and react normally. Reflexes active but otherwise negative. Fundi 
— retinal veins enlarged; indistinct blurring along the lower nasal quad- 
rants of both optic disks. 

Examination (September 20, 1915 — 25 months after injury). — Patient 
has been working as a foreman ever since the accident ; " I feel as well as 
ever." No headache nor dizzy spells; emotionally stable. Hearing of right 
ear possibly less acute than left ; air conduction greater than bone conduction. 
Reflexes negative. Fundi negative. 




ACUTE BRAIN INJURIES 235 

Last examination (August 26, 1918 — 60 months after injury). — Patient 
came to see me just before embarking for France in the American Expe- 
ditionary Force ; ' ' the army doctors never noticed my head and I did not 
tell them." No complaints. Sites of operations depressed and apparently 
new bone has formed over the median frontal area. Hearing- negative. 
Pupils equal and react normally. Reflexes active but otherwise negative. 
Fundi negative. 

Remarks. — Whenever there are definite signs of an increased intracranial 
pressure associated with a depressed fracture of the vault, it is always 
better surgical judgment to perform a homolateral subtemporal decompres- 
sion first, and then to elevate or remove the depressed area of the vault and 
thus avoid the complication of operative damage to the underlying cerebral 
cortex which otherwise might be extruded through the drral opening by 
the high intradural pressure ; in the presence of a marked increase of the 
intracranial pressure and the dura is not opened but merely the depressed 
area of bone elevated and removed, the benefits of such a procedure would 
be very small indeed, if any ; the dura must always be opened in order to 
lessen the increased intracranial pressure — the dura being inelastic in adults. 

It was very impressive in this patient following operation to observe the 
immediate subsidence of the signs pointing to an irritative and compressive 
lesion of the right hemisphere — the suggestive left Babinski, the absent 
left abdominal reflex and the immediate cessation of the discharge of blood 
and cerebrospinal fluid from the right ear. The danger of possible infection 
through this latter source is always greatly lessened by an early cranial 
decompression and drainage. 

It is very gratifying to ascertain in these patients having a definite 
impairment of hearing referable to the middle ear and resulting from the 
fracture of the adjacent bone and the consequent laceration of the tympanic 
membrane, that this impairment of hearing almost invariably markedly 
improves and in many patients the hearing returns to normal acuity follow- 
ing a normal natural repair of the laceration of the tympanic membrane ; 
usually within a period of a year, the improvement is a very definite one. 
It is only in those patients whose auditory nerve has been irreparably 
damaged, either by complete severance or by bony compression of it and 
thus the impairment of hearing being referable to the auditory nerve itself, 
that little or no improvement occurs and the end-result is bad. 

Case 39. — Recent fracture of base associated with compound depressed 
fracture of vault of skull ; definite signs of high intracranial pressure. Two 
operations — subtemporal decompression first, and then a removal of de- 
pressed area of bone. Excellent recovery. 

No. 075. — Luigi. Twenty-eight years. White. Married. Laborer. Italy. 

Admitted June 30, 1913, Polyclinic Hospital. Referred by Doctor 
Alexander Lyle. 

Operations (June 30, 1913 — 7% hours after injury). — 1st. Right subtem- 
poral decompression; second, removal of depressed area of bone. 

Discharged July 21, 1913 — 21 days after injury and operations. 

Family history negative. 

Personal history negative. 



236 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Present Illness. — While working in a new building, patient was struck 
upon the head by a wheelbarrow loaded with bricks falling a distance of 
4 stories ; immediate loss of consciousness for several minutes ; brought to 
the hospital in a truck. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 100°; pulse, 66; respiration, 16 (slightly irregular) ; blood-pressure, 
144. (Another example of retardation of pulse- and respiration-rates in a 
patient having an occipital injury.) Semiconscious. Laceration of scalp 
over right occipital bone ; gentle probing and retraction of scalp edges 
exposes a depressed fracture of the underlying occipital bone. Bleeding 
from right ear ; right mastoid ecchymosis. Pupils equal and react normally. 
Reflexes — knee-jerks exaggerated, especially left ; suggestive left Babinski ; 
abdominal reflexes present and equal. Fundi — retinal veins full and slightly 
tortuous; the nasal halves of both optic disks obscured by edema. (No 
lumbar puncture performed. No X-ray taken.) 

Treatment. — On account of the increased intracranial pressure and the 
absence of shock, an immediate operative relief of the intracranial pressure 
with drainage and then the elevation or removal of the depressed area of 
bone were advised. 

Operations (7 hours after admission). — 1st. Right subtemporal decom- 
pression : usual incision and bone removed ; no complications except the bone 
was very thick and hard. Dura slightly bluish and under a high tension ; 
upon incising it, blood-tinged cerebrospinal fluid spurted to a height of 
7 inches. Cortex tended to protrude, being very "wet" and edematous; 
arachnoid continued to "sweat" throughout the operation, so that much 
cerebrospinal fluid escaped and thus lessened the cerebral tension. Usual 
closure with 2 drains of rubber tissue inserted. 

2nd. Removal of depressed area of right occipital bone : retractors in- 
serted, exposing the depressed area ; small trephine opening made at outer 
edge of bony depression which was then rongeured away — to the diameter of 
iy 2 inches; dura had not been injured. Usual closure with 3 drains of 
rubber tissue inserted. Duration of both operations, 75 minutes. 

Post-operative Notes. — -Uneventful operative recovery; almost imme- 
diate improvement of both the local and general condition of the patient. 

Examination at discharge (21 days after admission). — Temperature, 
98.6°; pulse, 72; respiration, 20; blood-pressure, 140. Patient feels well 
except for general weakness and some dizziness. Laceration of scalp and 
decompression incision have healed per primam. Hearing of right ear im- 
paired ; bone conduction greater than air conduction ; otoscopic examination 
reveals a jagged laceration of upper posterior quadrant of right tympanic 
membrane. Pupils equal and react normally. Reflexes all exaggerated but 
otherwise negative. Fundi — nasal margins of both optic disks blurred; 
retinal veins enlarged. 

Examination (October 28, 1914 — 17 months after injury). — Works daily 
and has no real complaints; wishes, however, to "drink a little vino." 
Hearing of right ear practically normal. Pupils equal and react normally. 
Reflexes negative. Fundi negative. Both operative areas sunken; decom- 
pression site pulsates slightly. 



ACUTE BRAIN INJURIES 237 

Examination (April 21, 1916 — 34 months after injury). — No complaints. 
Reflexes negative. Fundi negative. 

Last Examination (August 10 ; 1918 — 62 months after injury). — No com- 
plaints. Operative areas depressed and a layer of hard new bone formation 
is present. Hearing negative ; air conduction greater than bone conduction 
in both ears. Reflexes negative. Fundi negative. 

Remarks. — It is unfortunate that no lumbar puncture was made in this 
patient; the importance of estimating accurately the degree of increased 
intracranial pressure was not then fully appreciated — it was then more a 
question of ascertaining the presence or not of blood in order to assert with 
greater certainty that a fracture of the skull was present (a belief now 
known to be most fallible and of no great importance in the treatment of 
the patient — surely not as to the advisability or not of a cranial decompres- 
sion) . No X-ray was taken in the belief that a fracture of the skull must be 
present since there was blood extruding from the right ear through a 
lacerated right tympanic membrane and associated with a right mastoid 
ecchymosis ; an X-ray*, besides, was not considered necessary because it was 
evident from the probing and palpation that a depressed fracture of the 
vault was present. Whenever possible, however, it is advisable to have 
cranial rontgenograms made for fear a. depression of the vault or other 
abnormality might be overlooked. 

The unusual high pressure revealed at operation in this patient so that 
the cerebrospinal fluid spurted to a height of 7 inches is impressive in that 
frequently the ophthalmoscopic and lumbar puncture tests do not reveal 
as high an intracranial pressure as exposed at operation, while they rarely if 
ever err in showing greater intracranial pressure than is really present. 

Case 40. — Acute fracture of base associated with a depressed fracture 
of vault of skull ; marked signs of an increased intracranial pressure. Two 
operations — subtemporal decompression first, then removal of depressed 
area of bone. Excellent recovery. 

No. 081.— David. Sixteen years. White. Single. School. U. S. 

Admitted September 11, 1913, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operations (September 12, 1913 — 1614 hours after injury). — First, right 
subtemporal decompression ; second, removal of depressed area of bone. 

Discharged September 21 ,1913 — 10 days after operations. 

Family history negative. 

Personal history negative. 

Present Illness. — While descending the stairway of the elevated railroad, 
patient slipped upon a banana peeling and fell headforemost to the pave- 
ment below — landing upon 2 men ; immediate loss of consciousness ; brought 
to the hospital in the ambulance. 

Examination upon admission (25 minutes after injury ), — Tempera- 
ture, 98°; pulse, 72; respiration, 24: blood-pressure, 120. Semiconscious 
and in shock (though the signs of shock are being overshadowed by the intra- 
cranial pressure as indicated by the relatively low pulse-rate) . Much vomit- 
ing of undigested food. Tender ecchymotic area over right temple. No 
bleeding from nose, mouth or ears; right orbit markedly ecchymosed ; right 



238 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

subconjunctival hemorrhage. Pupils equal and react normally. Reflexes — 
knee-jerks very sluggish but apparently equal ; no ankle clonus nor Babin- 
ski ; abdominal reflexes not obtained. Fundi — retinal veins enlarged ; mar- 
gins of optic disks clear. Lumbar puncture — cerebrospinal fluid clear and 
under an increased pressure (approximately 11 mm.). 

Treatment. — Expectant palliative ; careful observation to ascertain if the 
signs of high intracranial pressure should appear and thus make it advisable 
to perform the operation of subtemporal decompression after the signs of 
shock had subsided. 

Examination (16 hours after admission). — Temperature, 99.4°; pulse, 
60; respiration, 16; blood-pressure, 136. Conscious; complains of severe 

headache. Pupils equal and 
react normally. Reflexes ac- 
tive but otherwise negative. 
Fundi — retinal veins di- 
lated; nasal margins and 
nasal half of right optic disk 
obscured by edema. Lumbar 
puncture — clear cerebro- 
spinal fluid under increased 
pressure (approximately 14 
mm.). X-ray (Doctor A. J. 
Quimby ) — ' ' Y-shaped lines 
of depressed fracture over 
right frontal area — extend- 
ing into right orbit and 
downward into base" (Fig. 
66). 

Treatment. — wing to 
the increasing signs of a 

Fig. 66.— Extensive linear and depressed fractures of anterior ni g n intracranial pressure, it 

portion of vault associated with a high intracranial pressure; Wfl( j fTinncrlit i\c\ visa hip in rtf*r 

therefore, a subtemporal decompression first, to be followed by WaS in °UgUt dCLVlbdDie 10 per- 

the removal of the depressed area of bone. Excellent recovery. for m a right Subtemporal 

decompression first and then 
to elevate or remove the depressed area of bone and, whenever possible, 
through the upper part of the same operative incision. 

Operations (18 hours after injury). — 1st. Right subtemporal decompres- 
sion: usual incision, bone removed and no complications; underlying tem- 
poral muscle ecchymosed with clotted blood among the muscle fibres (this 
condition always indicates an underlying fracture of the bone and I have 
yet to see this sign fail; naturally the overlying scalp must not be ecchy- 
motic, otherwise a local injury could produce a similar condition) ; upon 
retracting the separated muscle fibres a transverse fracture was exposed, 
branching forward toward the orbit and downward toward the base; the 
bone was depressed to a depth of 2 cm. Dura very tense and upon incising 
it, clear cerebrospinal fluid spurted to a height of 7 inches; arachnoidal 
"sweating" very profuse, allowing the tense edematous cortex to pulsate 
normally before the end of the operation. Usual closure with 2 drains of 
rubber tissue inserted. 




ACUTE BRAIN INJURIES 239 

2nd. Removal of depressed area of bone : small curvilinear incision over 
depression of right posterior frontal area ; retractors inserted, revealing a 
depressed fracture. Small rongeurs inserted and an area 1 inch in diameter 
removed. Dura not injured and of normal appearance. Usual closure with 
2 drains of rubber tissue inserted. Duration of both operations, 60 minutes. 

Post-operative Notes. — Excellent operative recovery; the signs of in- 
creased intracranial pressure quickly lessened. 

Examination at discharge (10 days after admission). — Temperature, 
99° ; pulse, 78 ; respiration, 24 ; blood-pressure, 130. Patient in excellent con- 
dition and refuses to remain longer in the hospital ; no complaints except 
soreness over right side of head. Right orbit still slightly ecchymosed and 
right subconjunctival hemorrhage still persists. Pupils equal and react nor- 
mally. Reflexes active but otherwise negative. Fundi — nasal margins of 
both optic disks still blurred but not the nasal halves ; retinal veins enlarged. 
Decompression area tense and bulges slightly. 

Examination (April 23, 1915 — 19 months after injury). — No complaints ; 
graduates from high-school this year. Decompression area depressed and 
pulsates slightly. Reflexes negative. Fundi negative. 

Last Examination (May 23, 1918 — 56 months after injury). — Patient 
came for examination and to ascertain whether his former head injury 
would prevent him from entering the army. No complaints. Except for 
depressions at sites of former operations, the physical condition is negative 
and I see no reason why he should not be admitted to the service. Reflexes 
negative. Fundi negative. 

Remarks.— This case is a good illustration of the increased intracranial 
pressure being due, not to an intracranial hemorrhage (and it rarely is due 
to hemorrhage alone), but to an acute cerebral edema — either a temporary 
blockage of the cerebrospinal fluid or an increased secretion of it, and more 
probably the former. Although it is rather unusual for the cerebrospinal 
fluid intracranially to be perfectly clear in the presence of a fracture 
of both the vault and the base, yet it does occur, and particularly when the 
fracture is limited to the vault alone. From the standpoint of treatment 
and also prognosis, it is a question of increased intracranial pressure — 
whether it is due to hemorrhage or to cerebral edema matters little — the 
object of the treatment being to lessen this increased pressure, either by the 
natural means of absorption or by the mechanical means of subtemporal 
decompression and drainage. 

The clinical syndrome of temperature, pulse, respiration and blood- 
pressure in these traumatic cases is very significant and of much value in 
estimating the general condition of the patient, and in a less accurate manner, 
the presence or not of a definite increase of the intracranial pressure. Upon 
admission, the temperature being 98° and the blood-pressure 120 would 
indicate the condition of shock, and it would be expected naturally that the 
pulse- and respiration-rates would be possibly 100 and 30, respectively ; how- 
ever, the condition of mild shock being associated with a moderate degree 
of increased intracranial pressure as the signs of shock became less and less. 
the pulse- and respiration-rate was only 72 and 24 ami thus indicated that 
the signs of shock were gradually being overshadowed by the si^ns of an 
increasing intracranial pressure. This opinion is confirmed by the examina- 



2 4 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tion 16 hours later when the temperature was 99.4 and the blood-pressure 
136, whereas the pulse- and respiration-rate was 60 and 16 and thus indi- 
cating that the condition of shock had been entirely overcome and that the 
stage of increased intracranial pressure was now definitely established. 

Case 41. — Acute fracture of base associated with depressed fracture of 
vault of skull ; marked signs of high intracranial pressure. Two opera- 
tions — subtemporal decompression first, and later a removal of the depressed 
area of bone. Excellent recovery. 

No. 727. — Edward. Twenty-seven years. White. Single. Chauffeur. 
United States. 

Admitted November 17, 1916, Polyclinic Hospital. 

Operation (first) November 23, 1916 — 6 days after injury. Left sub- 
temporal decompression. 

Operation (second) November 30, 1916 — 13 days after injury. Removal 
of depressed area of bone. 

Discharged December 16, 1916 — 29 days after injury and 16 days after 
second operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was knocked down 
hy an automobile ; immediate loss of consciousness ; brought to the hospital 
in the automobile. 

Examination upon admission (20 minutes after injury). — Temperature, 
97.2°; pulse, 138; respiration, 30; blood-pressure, 112. Semiconscious; in 
severe shock. Large laceration of 2 inches over right posterior frontal bone ; 
gentle probing reveals simply a crack in the underlying bone. Profuse 
bleeding from nose; both eyes ecchymotic with bilateral subconjunctival 
hemorrhages. Pupils dilated and do not react to light. Reflexes cannot be 
elicited. Fundi negative. 

Treatment. — Expectant palliative; vigorous shock measures instituted; 
scalp laceration cleansed and dressed. 

Examination (24 hours after admission). — Temperature, 98.8°; pulse, 
110 ; respiration, 24 ; blood-pressure, 124. Stuporous and confused men- 
tally; very restless. Both eyes entirely closed from edema. Pupils equal 
but react sluggishly. Reflexes — knee-jerks exaggerated but equal; double 
ankle clonus and suggestive right Babinski ; abdominal reflexes present and 
equal. Fundi (Doctor J. A. Kearney) — "optic disks reddish; retinal veins 
dilated; details of fundus very indistinct — there being a definite blurring 
of the upper and nasal margins of both optic disks. ' ' Lumbar puncture — 
bloody cerebrospinal fluid under an increased pressure (approximately 
12 mm.). 

Treatment. — Expectant palliative. (The operation of cranial decompres- 
sion and drainage was not advised at this time, first, on account of the pres- 
ence of shock, and secondly, in the hope that the mild increased intra- 
cranial pressure would be lessened by natural absorption, making the 
operation unnecessary.) 

Examination (November 22, 1916 — 5 days after admission). — Tempera- 
ture, 99.8°; pulse, 74; respiration, 18; blood-pressure, 132. Conscious but 



ACUTE BRAIN INJURIES 241 

very drowsy ; complains of severe headache ' ' all over ' ' ; when aroused very 
restless and irritable. Scalp laceration healing per primam. Ecchymosis 
of both orbits less. Definite motor aphasia (incomplete) has developed dur- 
ing past 6 hours. (Patient, parents and grandparents are all right-handed. ) 
Pupils equal and react normally. Reflexes — knee-jerks very much exag- 
gerated but equal; double ankle clonus and double Babinski; abdominal 
reflexes absent. Fundi — retinal veins dilated; nasal halves of both optic 
disks entirely blurred. Lumbar puncture — straw-colored cerebrospinal 
fluid under marked increase of intracranial pressure (approximately 
16 mm.). 

Treatment. — As the signs of an increased intracranial pressure were be- 
coming more marked, it was thought advisable to lessen this pressure by 
mechanical means — that is, by a subtemporal decompression, in order that 
the patient would not only recover life but that the greatest ultimate 
improvement would occur. 

First Operation (6 days after admission). — Left subtemporal decom- 
pression and drainage. (The fact that the Babinski reflex appeared first 
on the right side and that a definite motor aphasia had occurred in a patient 
who was right-handed and whose parents and grandparents had all been 
right-handed, indicated that the left cortical hemisphere was possibly more 
involved than the right cortical hemisphere ; also the danger of infection 
from the laceration of the right scalp was greater in a right subtemporal 
decompression.) Usual vertical incision, bone removed and no complica- 
tions, Dura quite tense ; upon incising* it, straw-colored cerebrospinal fluid 
spurted several inches, exposing a very "wet" edematous cortex which 
tended to protrude but did not rupture. Much cerebrospinal fluid escaped, 
allowing the cortex to become less tense and then to pulsate almost normally. 
No definite supracortical or cortical clot exposed. Cortex very much con- 
gested but no punctate hemorrhages observed. Usual closure with 2 drains 
of rubber tissue inserted. Duration of operation, 38 minutes. 

Post-operative Notes. — Uneventful operative convalescence ; decompres- 
sion area bulged tensely for several days. 

Examination (November 29, 1917 — 12 days after admission and 6 days 
after operation). — Temperature, 99.6°; pulse, 76; respiration, IS: blood- 
pressure, 130. No complaints except dull heavy feeling in head — "no real 
headache. " Motor aphasia began to improve immediately after the de- 
compression operation, so that now speech is practically normal except for a 
slight slurring of polysyllabic words. Operative area bulging slightly ; 
healing per primam. Pupils equal and react normally. Reflexes active ; 
double exhaustible ankle clonus with double suggestive Babinski ; abdominal 
reflexes present but depressed, though equal. Fundi — retinal veins dilated ; 
edematous blurring of both nasal margins but only of nasal half of right 
optic disk (a very interesting observation inasmuch as the subtemporal 
decompression was performed on the left side). X-ray (Doctor W, 11. 
Stewart) — "depressed area of bone 2 inches in diameter lying over the 
right posterior frontal bone; line of fracture extends downward into the 
base" (Fig. 67). (Through an unfortunate oversight, no X-ray had been 
taken of this patient until this date and the importance of the findings is 
16 



242 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



self-evident ; it shows the necessity of rontgenograms in all patients having 
head injuries.) 

Treatment. — The removal of the depressed area of bone advised in order 
to lessen the danger of future complications. 

Second Operation (13 days after admission). — Removal of depressed area 
of bone ; vertical incision of 2 inches over posterior portion of right frontal 
bone; retractors inserted, exposing a depressed area of one silver dollar in 
size and to a depth of almost one inch. Bony edges enlarged by small ron- 
geurs and the depressed area of bone extracted. Dura intact and of normal 

appearance. Usual closure 
with 2 drains of rubber 
tissue inserted. Duration of 
operation, 16 minutes. Un- 
eventful operative recovery. 
Examination at discharge 
(29 days after admission and 
16 days after second opera- 
tion). — Temperature, 98.8°; 
pulse, 78; respiration, 20; 
blood-pressure, 132. No com- 
plaints except general sore- 
ness of head. Operative areas 
flush with surrounding 
scalp ; decompression site 
pulsates normally. Pupils 
equal and react normally. 
Reflexes — knee-jerks active 
but equal ; bilateral exhaust- 
ible ankle clonus and sugges- 
tive left Babinski; abdomi- 
nal reflexes present and 
equal. Fundi — retinal veins 
enlarged; slight hazy blur- 
ring of nasal margins of both 
optic disks. 

Examination (August 20, 1917 — 9 months after injury). — No complaints 
except for dizziness in the morning ; also ' ' I Ve lost my nerve — I can 't go 
faster than 30 miles." No signs of motor aphasia can be elicited. Both 
operative areas have become depressed. Pupils equal and react normally. 
Reflexes active but otherwise negative. Fundi negative. 

Last Examination (September 12, 1918 — 22 months after injury). — 
Patient comes for examination and to receive certificate for draft exemption. 
No real complaints referable to former head injury. Reflexes negative. 
Fundi negative. Limited military service advised. 

Remarks. — Although in most cases of depressed fracture of the vault 
of the skull associated with increased intracranial pressure, it is more im- 
portant to relieve this increased pressure by means of the subtemporal 
decompression than to elevate or remove the depressed area of the vault, 




Fig. 67.— An unsuspected extensive and deeply 
fracture of posterior portion of right frontal bone, disclosed by 
the X-ray and necessitating its removal for fear of future com- 
plications; a left subtemporal decompression had already been 
performed to lower the increased intracranial pressure. Excel- 
lent recovery. 



ACUTE BRAIN INJURIES 243 

yet the depressed area should always be elevated and removed when possible ; 
the value of careful rontgenograms for patients of this type and I believe 
for all patients having cranial injuries, is well illustrated in this patient, 
and it was most important that the depressed fracture of this extent should 
have been removed, otherwise the great danger of possible future complica- 
tions. If there had not been localizing signs pointing to the left cerebral 
cortex as the site of the greater impairment, the decompression operation 
would naturally have been performed upon the right side and undoubtedly 
this depression of the vault would then have been ascertained; however, 
if this depression had been located in another area of the vault, it too would 
have been overlooked unless careful rontgenograms had been made. 

The gradual increase of the intracranial pressure as measured at lumbar 
puncture and as revealed by the ophthalmoscope is very impressive, and it 
is these careful and repeated examinations which make it possible for the 
signs of increased intracranial pressure to be revealed and thus the danger- 
ous compressive effect of extreme intracranial pressure anticipated — both the 
immediate results and, if death is avoided, then the ultimate remote effects 
of a prolonged increase of this intracranial pressure. 

The disappearance of the paraphasia, following the left subtemporal 
decompression and the improvement of the reflexes which now pointed to 
the right cerebral cortex (the site of the depressed area of the vault) as 
being the greater impaired, was a very interesting observation, and then for 
all of these signs of cerebral impairment to disappear following the second 
operation and removal of the depressed area of bone, is worthy of comment. 

Acute severe brain injuries associated with a high intracranial pressure 
due to hemorrhage and to cerebral edema, and requiring the cranial opera- 
tion of subtemporal decompression. 

The presence or not of a fracture of the skull in these patients having a 
severe brain injury associated with a high intracranial pressure is important 
only from the standpoint of possible drainage of blood and cerebrospinal 
fluid through the line or lines of fracture into the ear, nose or subcutaneous 
tissues of the scalp, and thus a sufficient lowering of the increased intra- 
cranial pressure will result so that the operation of decompression and 
drainage may be avoided. Fortunately, in some of the patients, the base or 
vault of the skull has been so badly fractured into several movable frag- 
ments with profuse drainage that a decompression is not necessary — a sort 
of natural decompression having been performed ; in this manner, the intra- 
cranial pressure is relieved to such a degree that the patient recovers to the 
surprise of all. An ophthalmoscopic and spinal manometric examination in 
these patients, however, would show that the intracranial pressure had not 
been markedly increased; this explanation undoubtedly accounts for the 
recovery of those patients reported as having the most severe forms of 
comminuted fractures of the skull and yet the recovery is uneventful. In 
other patients, however, the symptoms and clinical signs at first indicate 
only a mild type of brain injury with and without a fracture of the skull. 
and yet the condition of the patient gradually becomes worse, unconscious- 
ness supervenes, and the patient dies with the typical signs of medullary 
collapse, usually on the fifth or sixth day after the accident, or. in some 



244 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

cases, as late as the fourteenth day ; I am confident that if repeated oph- 
thalmoscopic and spinal manometric examinations had been made, the in- 
creasing intracranial pressure (apparently "latent" clinically) would have 
been ascertained and its immediate relief by a cranial decompression and 
drainage would have saved many of these patients. 

Even if the condition of the patient is carefully followed by repeated 
ophthalmoscopic and the routine neurological examinations, a definite prog- 
nosis regarding recovery must be very guarded and naturally should not 
be given ; shock, individual resistance, and the other possible complications 
are such important factors in each patient that any definite prognosis is 
most hazardous ; in addition to the great danger of medullary compression 
and, if this danger should be avoided, the possibility of post-traumatic con- 
ditions appearing and making the after-life of the patient most pitiable, 
there is still the ever-present risk of pneumonia occurring in patients confined 
to their beds in a semiconscious condition and especially is this true of 
patients over fifty, and if alcoholic to any degree ; the danger of pneumonia 
following an anesthetic, if properly administered, is small in comparison. 

If the intracranial pressure in these patients has reached such a height 
that the expectant palliative method of treatment is no longer considered 
sufficient to obtain the best results, both immediate and remote, then the 
mechanical relief of this intracranial pressure by means of the subtemporal 
decompression and drainage is advisable and at an early date when the 
condition of the patient is still good; the operation must not be delayed 
until the patient has reached the severe stage of extreme medullary compres- 
sion — and surely not that of medullary edema, as it is then too late to obtain 
a living patient. Upon performing the operation of subtemporal decom- 
pression, if it should be found that the intracranial pressure is extreme 
and especially of the swollen edematous type with very little escape of 
cerebrospinal fluid and the cerebral cortex pulsates slightly if at all, then a 
similar decompression should be immediately performed upon the other 
side of the head — that is, a bilateral decompression. The benefit of this 
second operation in these selected patients outweighs the added stock of the 
second operation and this method has proved beneficial in a number of 
patients. Only about 5 per cent, of the patients requiring the operation of 
cranial decompression in this series of cases had a bilateral decompression 
performed and the results were excellent ; in this manner, not only was the 
recovery of life greater, but the ultimate result of the former normality was 
more frequently obtained than would have been possible following an 
incomplete relief of the increased intracranial pressure. 

It rarely occurs in these patients that the hemorrhage is of such a large 
amount that it alone is responsible for the height of the intracranial pres- 
sure ; it is usually due to a subdural hemorrhage associated with a cerebral 
edema of varying degree ; of these two factors, the acute condition of cerebral 
edema is probably of greater amount and frequency and therefore of the 
more importance ; the formation of supracortical adhesions and of cystic 
conditions, however, results from hemorrhage, and therefore its remote 
effects, unless it is drained early, may be serious, especially when associated 
with a varying degree of chronic cerebral edema. At the operation, as much 



ACUTE BRAIN INJURIES 245 

as possible of the free intracranial blood should be drained and allowed 
to escape, but the relief of the increased intracranial pressure is of prime 
importance, and then, if possible and at the same time, the drainage of the 
hemorrhage and the excess cerebrospinal fluid is of next importance — and 
thus the increased intracranial pressure is doubly relieved. No patient, 
however, should be subjected to the risk of an osteoplastic "flap" operation 
in search of small localized areas of hemorrhage — an unimportant factor in 
the immediate condition of the patient. 

Recent severe brain injuries with high intracranial pressure associated 
with intracranial hemorrhage; unilateral decompression for the patients 
where the intracranial pressure is not extreme, and a bilateral decompression 
for only those patients having an extremely high intracranial pressure. 
Excellent recovery. 

A. Unilateral decompression. 

Case 42. — Acute severe brain injury ; marked signs of high intracranial 
pressure associated with subdural hemorrhage. Left subtemporal decom- 
pression and drainage. Excellent recovery. 

No. 037. — James. Sixty-five years. White. Widower. "Retired." 
Ireland. 

Admitted June 8, 1913, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operation June 8, 1913 — 33 hours after injury. Left subtemporal 
decompression and drainage. 

Discharged June 22, 1913 — 14 days after operation. 

Family history negative. 

Personal History. — Patient has not worked since 1881, when his wife 
died; is shiftless and a "loafer" (statement of brother). 

Present Illness. — No definite history obtainable except that patient, while 
drunk, was thrown out of a saloon into the street, striking upon his head ; 
apparently unconscious until the arrival of ambulance, which brought him 
to the hospital. 

Examination upon admission (2 hours after injury). — Temperature, 
97.8°; pulse, 88 ; respiration, 20; blood-pressure, 138. Practically uncon- 
scious, as he merely groaned upon being aroused with difficulty; in mild 
shock. Bleeding profusely from left ear ; left mastoid ecchymosis. Pupils — 
left pupil smaller than right; sluggish reaction to light. Reflexes: knee- 
jerks — right more active than left ; right Babhrski ; abdominal reflexes not 
obtained. Fundi — both retinae very much congested but optic disks not 
obscured. Lumbar puncture — cerebrospinal fluid blood-tinged and under 
increased pressure (approximately 13 mm.). 

Treatment. — Expectant palliative ; shock measures ; careful observation 
at frequent intervals to ascertain whether the intracranial pressure would 
become more increased as the signs of alcoholism disappear. 

Examination (30 hours after admission).— Temperature. 99.8°: pulse. 
72; respiration, 18; blood-pressure, 144. Patient has become more con- 
scious. Bleeding from left ear has ceased; otoscopic examination reveals a 
tear in the posterior half of left tympanic membrane. Vomiting profusely 
of beer and undigested food has also ceased. Pupils — left larger than eight ; 



246 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

does not react to light. Reflexes : knee-jerks — right more active than left ; 
exhaustible right ankle clonus and right Babinski; abdominal reflexes — 
right cannot be obtained. Fundi — definite enlargement of retinal veins; 
distinct blurring of nasal halves of both optic disks, especially left. Lum- 
bar puncture — blood-tinged cerebrospinal fluid under increasing pressure 
(approximately 17 mm.). 

Treatment. — It was now thought advisable to perform a left subtemporal 
decompression as the signs of intracranial pressure were increasing. 

Operation (31 hours after admission). — Left subtemporal decompres- 
sion: usual vertical incision, bone removed and no complications; upon 
retracting the underlying temporal muscle, there was exposed a transverse 
fracture of the squamous portion of the temporal bone — extending back- 
ward and downward; a bony opening of almost 3 inches in diameter was 
made. Dura very tense and bluish; upon incising it, almost pure blood 
welled out of dural opening, exposing a supracortical blood clot over 
1 c.c. in thickness; this exposed clot was easily removed by salt solution 
and forceps. Cortex itself edematous and congested but otherwise negative ; 
pulsated normally at end of operation. Usual closure with 2 drains of 
rubber tissue inserted. Duration of operation, 45 minutes. 

Post-operative Notes. — Excellent operative recovery ; blood-tinged cere- 
brospinal fluid continued to drain for 2 days; operative incision healed 
per primam. 

Examination at discharge (14 days after admission). — Temperature, 
99° ; pulse, 76 ; respiration, 22 ; blood-pressure, 140. No complaints, but he 
insists upon leaving the hospital ; as patient had no one to take care of 
him at home, it was thought advisable to transfer him to Bellevue Hospital for 
convalescence. Site of decompression opening bulging slightly; pulsates 
normally. Otoscopic examination reveals an almost closed laceration of the 
posterior portion of left tympanic membrane ; bone conduction greater than 
air conduction in left ear. Pupils equal and react normally. Reflexes active 
but otherwise negative. Fundi congested but otherwise negative. 

Examination (January 10, 1916 — 30 months after injury). — Patient 
remained on the Island for 6 weeks ; then returned home and has been 
leading the same life as before the injury — "doing nothing." No com- 
plaints, except those due to alcoholism. Hearing negative ; air conduction 
greater than bone conduction. Reflexes negative. Fundi negative. 

Last Report (March 10, 1918 — 57 months after injury). — Letter from 
brother states: "James died day before yesterday from pneumonia." 

Remarks. — The pupillary status of this patient was interesting from 
the standpoint that the ipsolateral cortical irritation was first exhibited 
by the contracted left pupil and its sluggish reaction to light ; then as the 
irritative effects of the left supracortical hemorrhage were overshadowed by 
the paralytic compressive effect of an increasing amount of hemorrhage, then 
the contracted left pupil gradually enlarged and became dilated and would 
not react at all to light. This inequality of the pupils in these patients 
is of great localizing significance ; the findings at the left subtemporal decom- 
pression confirmed these observations. 

The negative fundal findings at the ophthalmoscopic examination upon 



ACUTE BRAIN INJURIES 247 

admission confirmed the presence of initial shock — the temperature then 
being 97.8 ; at the examination 30 hours after admission, there were definite 
signs of pressure in both fundi and particularly the left, and at this 
examination the temperature had ascended to 99.8° and the blood-pressure 
to 144, whereas the pulse- and respiration-rates had decreased to 72 and 18, 
respectively, — definite signs pointing to the overshadowing of the initial 
shock by an increasing intracranial pressure. It is unfortunate that a 
second lumbar puncture was not performed at this time, as it would have 
undoubtedly shown a higher pressure than at the first examination. 

It is to be regretted that a post-mortem examination could not have 
been performed upon this patient and to have ascertained the intracranial 
condition following an interval of almost 5 years since the brain injury. 

The right pupil being larger than the left and apparently dilated more 
than normally, together with the weakness of the lower portion of the left 
side of the face, indicated a right cortical involvement ; however, it is pos- 
sible that the left pupil was abnormally contracted due to homolateral 
cortical irritation, and that the weakness of the lower portion of left side 
of face was not cortical in type but mildly peripheral in type due to a slight 
edematous compression of the left facial nerve caused by the proximity of the 
fracture of the skull producing a laceration of the left tympanic membrane, 
as revealed by otoscopic examination. A right subtemporal decompression 
would have been advisable in this case if the reflexes had not been exagger- 
ated on the right side, and if the signs of increased intracranial pressure had 
been exceedingly high, then it would have been better judgment, in a right- 
handed individual, to have performed a right subtemporal decompression 
first, to be followed, if necessary, by a left subtemporal decompression. 

The definite temporary recovery obtained in this patient is most grati- 
fying and especially in view of his age of 65 years at the time of the 
injury. It is indeed surprising how quickly these patients recover follow- 
ing an efficient subtemporal decompression and drainage — even patients 
having most serious signs, such as convulsive seizures, paralyses and ex- 
treme intracranial pressure, provided this pressure can be relieved early — 
as early as possible following the subsidence of the initial shock. 

Case 43. — Acute severe brain injury without a fracture of the skull ; signs 
of high intracranial pressure associated with subdural and subarachnoid 
hemorrhage. Left subtemporal decompression and drainage. Excel- 
lent recovery. 

No. 092. — Hilary. Eighteen years. White. Single. College. U. S. 

Admitted March 21, 1914, Polyclinic Hospital. Referred by Doctor 
T. J. Kearns. 

Operation March 21, 1914 — 5 days after injury. Left subtemporal 
decompression and drainage. 

Discharged March 31, 1914 — 10 days after operation. 

Family history negative; no history of epilepsy, insanity or nervous 
diseases; no alcoholism. 

Personal history negative; 9 months' baby; normal delivery: never had 
convulsions. Well educated; 5th year Latin; speaks German, French and 
Greek (even). 



248 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Present Illness. — Five days ago (March. 16, 1914) while at bat, patient 
was struck by a pitched ball over left temporo-parietal region ; unconscious 
for several minutes but was unable to finish the game ; walked to his home 
for supper that evening. No bleeding from ears nor nose ; no ecchymoses. 
Twelve hours later, patient had an epileptiform attack — 25 minutes' dura- 
tion ; its character was not observed other than being a general convulsion 
with frothing at the mouth ; after this attack, a weakness of the right arm 
was noticed. Eighteen hours later — a second convulsion of the Jacksonian 
type occurred — the spell beginning in the right arm, with frothing at the 
mouth, then the right side of face, right leg and finally a general convulsion 
lasting 3 minutes. Since then, patient has had 5 convulsions — the last one 
being 12 hours ago and was the most severe one — lasting 4 minutes, to be 
followed by extreme prostration. 

Consultation at Patient's Home (March 21, 1914, 4 p.m. — 5 days after 
injury). — Temperature, 99° ; pulse, 80; respiration, 16; blood-pressure, 126. 
Conscious but confused mentally ; memory impaired for recent events. Dis- 
tinct motor aphasia and paraphasia — unable to find the correct word at 
times, uses words incorrectly and frequently could not repeat single words ; 
patient, however, was conscious of his mistakes. No agraphia. Pupils — 
left slightly larger than right and reaction to light sluggish. No ocular 
paralysis. No bleeding from nose, mouth nor ears ; no mastoid ecchymosis. 
Definite weakness of right side of body, particularly of right arm — right- 
hand grip being much weaker than left. Reflexes — knee-jerks more active 
on right side ; no ankle clonus but a right Babinski ; abdominal reflexes — right 
distinctly depressed. Fundi — retinal veins dilated, nasal margins, particu- 
larly of left optic disk, blurred and obscured by edema. 

Treatment. — On account of the localized convulsions, the motor aphasia 
and paraphasia (the patient, his parents and grandparents being all right- 
handed), the increased reflexes and weakness of the right side, together 
with the signs of increasing intracranial pressure, the patient was advised 
to be taken immediately to the hospital and a left subtemporal decompres- 
sion performed. 

Examination upon admission to hospital (March 21, 1914, 9 p.m.). — 
Temperature, 99.2° ; pulse, 78 ; respiration, 18 ; blood-pressure, 140. Patient 
has become more stuporous though no convulsions have occurred since the 
preceding examination. Paresis of right side of body has increased, espe- 
cially of right arm and of right side of face. Aphasia and paraphasia have 
also become more marked, though a careful examination cannot be made 
on account of the mental impairment. Pupils — left larger than right and 
reacts sluggishly to light. Reflexes : knee-jerks — right much more exag- 
gerated than left ; definite right patellar and right ankle clonus and right 
Babinski ; right abdominal reflex absent. Fundi — nasal halves of both optic 
disks, particularly the left, obscured by edema. 

Treatment. — Left subtemporal decompression and exploration advised. 

Operation (March 21, 1914, 10 p.m. — 5 days after injury). — Left sub- 
temporal decompression: usual vertical incision (somewhat anterior to usual 
line), bone removed and no complications; the bone itself, however, was 
unusually thin in this area but no fracture ascertained. Dura was under 









ACUTE BRAIN INJURIES 



249 




high tension and upon incising it, blood-tinged cerebrospinal fluid escaped ; 
upon enlarging dural opening there was exposed a bluish subarachnoid 
clot — one-fourth inch in thickness and apparently 2 inches in width, 
extending upward and backward from the anterior portion of the bony 
opening over the posterior portion of the left third frontal convolution, 
and then extending backward and upward over the motor area of the face 
and arm ; surrounding cortex edematous but otherwise normal. The arach- 
noid membrane overlying the hemorrhagic clot was incised, allowing much 
of the clotted blood to escape, but no attempt was made to remove the entire 
hemorrhage itself for fear of damaging the underlying cortical cells. Much 
cerebrospinal fluid escaped, allowing the brain to pulsate normally. Usual 
closure with 2 drains of 
rubber tissue inserted. Du- 
ration, 50 minutes. Un- 
eventful operative recovery. 

Examination at dis- 
charge (5 days after injury 
and 10 days after opera- 
tion) . — T emperature, 
98.8°; pulse, 80; respira- 
tion, 22 ; blood-pressure, 
128. Speech impairment 
has practically disappeared, 
though slight slurring of 
words occurs when test 
phrases are used. Weak- 
ness of right side of body 
much improved, but it can 
still be elicited by the usual 
tests — hand grip, etc. De- 
compression area protrudes 
slightly; normal pulsation. 
Pupils equal and react nor- 
mally. Reflexes — right more active than left; no Babinski nor ankle 
clonus ; abdominal reflexes present and equal. Fundi — retinal veins slightly 
dilated ; nasal margins of optic disks, particularly the left, not distinct. 

Examination (June 15, 1914 — 3 months after injury). — No complaints. 
No convulsions ; no aphasia nor paraphasia elicited. No weakness of right 
side of body. Decompression area slightly depressed ; normal pulsation. 
Reflexes negative. Fundi negative. 

Examination (September 12, 1916 — 30 months after injury).— No com- 
plaints; comes for physical examination before entering law school next 
month. No aphasia nor paraphasia. No weakness of right side of body. 
Reflexes negative. Fundi negative. The photograph shows the normal 
depressed appearance of the decompression area (Fig. 68). 

Last Examination (November 6, 1918 — 56 months after injury V — 
Patient wishes a certificate of physical well-being in the hope that lie may 
enlist in the army. No complaints. Decompression area depressed ; does not 




Fig. 68. — The vertical scalp incision of the decompression area 
exposed by brushing the hair apart — two and one-half years 
following the operation. No complaints. Excellent recovery. 



250 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

pulsate — due possibly to new bone formation. Reflexes negative. Fundi neg- 
ative, i, Patient was admitted to limited service branch of National Army.) 

Remarks. — It will be very interesting to follow this patient over a longer 
period of years to ascertain his complete recovery or not. The danger of 
possible epileptiform seizures of the minor and major type must be con- 
sidered in the ultimate prognosis ; anyone having convulsions and therefore 
whose cerebral cortex has once reached a condition of irritability sufficient 
to result in motor convulsive seizures, is more susceptible to epileptiform 
spells later, and these patients must be most careful of their habits — espe- 
cially of diet, which should consist chiefly of non-proteid foods and of small 
amount, and the total abstinence of alcohol in any form; coffee likewise 
should be prohibited for these patients. Any unusual strain, mental and 
physical, should be avoided. 

The almost disappearance of the symptoms and signs referable to the 
left cerebral cortex within 12 hours after the operation was most impressive ; 
the impairment of speech improved so rapidly that it was most surprising 
to the patient himself, who remarked that "'words come now so easily." 

It is unfortunate that a lumbar puncture with a measurement of the 
pressure of the cerebrospinal fluid was not performed upon this patient ; the 
signs of pressure were so definite and the localization so indicative of the 
left cerebral cortex, especially the Jacksonian convulsive seizures, that the 
lumbar puncture was not considered necessary. To-day. however, it would 
be performed in a similar patient, and it should always be performed upon 
these patients as the most accurate method of determining the intra- 
cranial pressure. 

Case 44. — Acute severe brain injury ; signs of high intracranial pres- 
sure associated with subdural and cortical hemorrhage. Left subtemporal 
decompression and drainage. Excellent recovery. 

No. 280. — David. Twenty-six years. TVhite. Single. Chauffeur. TJ. S. 

Admitted June 9. 1915. Polyclinic Hospital. 

Operated June 10. 1915 — 20 hours after injury. Left subtemporal 
decompression and drainage. 

Discharged June 28. 1915 — 18 days after operation. 

Family hist cry negative. 

Personal history negative. 

Present Illness. — Patient was brought to the hospital by strangers in a 
taxicab and then abandoned — no history being obtained. 

Examination upon admission (unknown interval of time following 
injury). — Temperature. 99.6°: pulse. 74: respiration. 18: blood-pressure. 
138. L'nconscious but can be aroused with difficulty ; unable to answer 
questions rationally. Extensive laceration of scalp to the left of the occipital 
protuberance ; careful probing reveals no underlying fracture. Profuse 
hemorrhage from right ear ; right mastoid ecchymosis. Pupils — left larger 
than right and reacts to light sluggishly. Reflexes : knee-jerks — right more 
active than left ; exhaustible right ankle clonus and right Babinski ; abdom- 
inal reflexes increased equally. Fundi: retinal veins dilated: nasal halves 
of optic disks blurred — left possibly more than right. Lumbar puncture — 
blood-tinged cerebrospinal fluid under pressure ( approximately 13 mnO . 



ACUTE BRAIN INJURIES 



2*1 



Treatment. — Expectant palliative; scalp laceration widely shaved, 
cleansed and loosely sutured with 2 drains of rubber tissue inserted. 

Examination (18 hours after admission). — Temperature, 100.2°; pulse, 
66; respiration, 16; blood-pressure, 140. Patient conscious but confused 
mentally and badly oriented. Definite paraphasia present. Pupils — left 
widely dilated and does not react to light. Reflexes: knee-jerks — right 
greater than left ; right ankle clonus and right Babinski ; abdominal re- 
flexes increased — left more than right. Fundi — both optic disks blurred 
by edema but no measurable papilledema ; retinal veins dilated and tortuous. 
Lumbar puncture — bloody cerebrospinal fluid under high pressure (approxi- 
mately 16 mm.). No definite weakness of right side of body elicited. 

Treatment. — Left subtemporal decompression advised for fear the in- 
creasing intracranial pressure would produce an extreme medullary compres- 
sion and thus possibly precipitate a medullary edema ; it was thought advisa- 
ble to operate now rather than to wait until the patient might enter a far 
more serious condition of medullary compression, when it would be very 
doubtful if the patient would recover life itself. 

Operation (June 12, 1915 — 20 hours after admission). — Left subtem- 
poral decompression : usual vertical incision, bone removed and no compli- 
cations; no fracture of bone ascertained in this area. Dura tense and 
bluish ; upon incising it, bloody cerebrospinal fluid spurted to a height of 
5 inches, and upon enlarging the dural opening a very "wet" edematous and 
congested cortex with numerous punctate hemorrhages in it tended to pro- 
trude under high tension ; the cerebral tension was so high that a small 
rupture of the temporal lobe beneath the Sylvian fissure occurred. Much 
blood and cerebrospinal fluid escaped so that the brain pulsated at the end of 
the operation. No large clots ascertained. Usual closure with 2 drains of 
rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful operative recovery, although patient 
was irrational for 3 days following the operation, and he was mentally con- 
fused for almost 10 days after operation — getting out of bed and insisting 
upon going home ; incision healed per primam. 

Examination at discharge (19 days after admission and 18 days after 
operation). — Temperature, 99°; pulse, 70; respiration, 20; blood-pressure, 
134. No complaints. Patient unusually restless and excitable and does not 
sleep well. Decompression opening bulges under high pressure ; pulsation 
normal. Pupils equal and react normally. Hearing impaired in right ear ; 
otoscopic examination reveals a small laceration of posterior portion of right 
tympanic membrane. Reflexes : active but otherwise negative ; abdominal 
reflexes increased but equal. Fundi — nasal margins of both optic disks 
obscured by edema but nasal halves and temporal margins are clear and 
distinct; retinal veins enlarged. X-ray (Doctor A. J. Quimby) — "nega- 
tive for fracture of the skull." 

Examination (January 10, 1917 — 18 months after injury ). — No com- 
plaints ; works daily. Decompression area depressed and pulsates normally. 
No impairment of hearing of right ear; air conduction greater than bone 
conduction. Reflexes : active but otherwise negative ; abdominal reflexes 
active but equal. Fundi negative. 



252 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Last Examination (September 10, 1918 — 39 months after injury). — 
Patient comes to see me before embarkation with the army. No com- 
plaints. Otoscopic examination reveals a normal right tympanic membrane ; 
hearing of right ear apparently normal (rough tests of watch, etc.). Re- 
flexes active but otherwise negative. Fundi negative. Decompression area 
depressed and apparently being filled in with new bone formation. 

Remarks. — Although the fracture in this patient was undoubtedly on the 
right side, causing a rupture of the right tympanic membrane, yet a left 
subtemporal decompression was performed because the signs of cortical in- 
volvement indicated a left intracranial lesion beside the general increased 
intracranial pressure ; as is well known and as this case illustrates, the frac- 
ture of the skull is possibly the least important factor to be considered in 
intracranial injuries. It is possible that the fracture extending through 
the right ear permitted the intracranial blood over the right hemisphere 
to escape through the right auditory canal and thus there were no signs of 
a lesion of the right hemisphere, whereas the left hemisphere not having 
any outlet for its supracortical "free" blood exhibited the signs of its 
irritation and impairment — paraphasia (the patient being right-handed), 
dilated left pupil and non-reacting to light, increased deep reflexes on the 
right side in addition to the right ankle clonus and right Babinski while 
the right abdominal reflexes were absent. Thus the right cerebral hemis- 
phere may have been ' ' decompressed ' ' and drained through the right ear, 
and the left cerebral hemisphere not being "decompressed" (to the extent 
of the right hemisphere) gave the greater evidence of impairment — beside 
the signs of a general increase of the intracranial pressure. 

The very early return to normal function of the right ear within a 
period of 18 months is very impressive ; naturally, this excellent result is only 
possible in the absence of middle ear infection following the laceration of 
the tympanic membrane, and when the line of fracture has in no way per- 
manently damaged the transmitting mechanism of the tympanic ossicles or 
of the internal ear and auditory nerve itself; these latter impairments are 
usually permanent. 

To make the otoscopic examination at the time of the patient's admis- 
sion to the hospital and in the presence of a profuse discharge of blood 
from either ear, is a distinctly dangerous procedure and should never be 
undertaken for fear of introducing infection into the middle ear by the 
swabbing out of the external auditory canal in order to obtain a clear view 
of the tympanic membrane ; many cases of local and general meningitis 
with or without the complication of brain abscess are frequently produced 
in this manner ; it is always wiser to wait until the discharge of blood and 
cerebrospinal fluid has ceased before an otoscopic examination is made. In 
many patients the rapidly increasing signs of the intracranial pressure 
are undoubtedly due to cerebral edema rather than to an intracranial 
hemorrhage itself; the "natural" decompression by means of drainage 
through a ruptured tympanic membrane is not always sufficient to lessen 
markedly the increasing intracranial pressure ; many patients, however, are 
thus spared an operation by means of this sort of "natural" decompression. 

A measurement of the pressure of the cerebrospinal fluid at lumbar 



ACUTE BRAIN INJURIES 253 

puncture should always be performed upon these patients, as we now know 
that it is a much more accurate and delicate test of intracranial pressure 
than the ophthalmoscopic examinations of the fundi ; even in conditions 
of mild initial shock and where the fundi are negative, yet it is frequently 
possible to find a pressure of the cerebrospinal fluid of approximately 12 
and even 14 mm. ; a second lumbar puncture later upon many of these 
patients would undoubtedly register a much higher pressure. 

This patient is a good illustration of a serious brain injury and yet no 
fracture of the skull could be demonstrated; the fracture may have been 
present but it in itself is not an important factor in the diagnosis and 
treatment of brain injuries ; the rontgenogram was not taken until the 
patient was well enough to be discharged and then merely as a question 
of record and for fear that a depressed fracture of the vault might be 
overlooked. No cranial operation to relieve the increased intracranial pres- 
sure in these patients should be delayed merely in order to obtain an 
X-ray picture of the skull ; the operation is not performed for the fracture 
nor on account of the fracture. 

The early fundal signs of increased intracranial pressure revealed by 
the ophthalmoscope within one hour after the injury can occur so quickly 
following cranial injuries only in the absence of shock, or as the result of a 
large hemorrhage occurring immediately following the cranial injury, and 
even in this latter condition the consequent shock would tend to lessen this 
increased intracranial pressure. 

It is most unusual in these patients having cranial injuries to demon- 
strate increased abdominal reflexes, as the usually associated factor of 
shock tends to abolish them, and if shock is not present in a marked degree 
but an increased intracranial pressure, then this latter factor tends to 
depress the abdominal reflexes; in fact, if the abdominal reflexes are not 
equal, the depressed ones are opposite the side of the greater cortical 
compression — that is, one cerebral hemisphere more seriously impaired and 
compressed produces on the opposite side of the body increased deep 
reflexes but diminished superficial reflexes, such as the abdominal reflexes. 
It was, therefore, very surprising to elicit increased abdominal reflexes in 
this patient before operation, and they remained increased at every exam- 
ination subsequent to the operation. 

Case 45. — Acute severe brain injury ; signs of a high intracranial pres- 
sure associated with subdural and subarachnoid hemorrhage. Repeated lum- 
bar punctures. Left subtemporal decompression and drainage. Excel- 
lent recovery. 

No. 283. — Gustave. Twenty-eight years. White. Single. Elevator- 
man. U. S. 

Admitted June 10, 1915, Polyclinic Hospital. 

Operation June 18, 1915 — 8 days after injury. Left subtemporal 
decompression and drainage. 

Discharged July 18, 1915 — 30 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — "While working in a department str.ro, patient fell a 



254 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

distance of one story down the elevator shaft ; immediate loss of conscious- 
ness ; brought to the hospital in the ambulance. 

Examination upon admission (1 hour after injury). — Temperature, 
97.6°; pulse, 94; respiration, 28; blood-pressure, 118. Semiconscious; in 
moderate degree of shock. Profuse bleeding from left ear; left mastoid 
ecchymosis. Pupils slightly dilated but react to light normally. Reflexes 
obtained with difficulty but otherwise negative. Fundi negative. 

Treatment. — Expectant palliative; vigorous shock measures instituted. 
Within 12 hours patient recovered from the condition of shock, became 
more conscious, complaining of severe headache, and after 48 hours, patient 
became more and more drowsy ; slept for long periods of time and began to 
show definite signs of an increased intracranial pressure. Repeated lumbar 
punctures were performed on six successive days and 15-20 c.c. of clear cere- 
brospinal fluid were removed each time under high pressure (approximately 
14-17 mm.) ; the last puncture and withdrawal of fluid was on June 18, 1915. 

Examination (June 18, 1915 — 8 days after admission). — Temperature, 
101.2°; pulse, 66; respiration, 16; blood-pressure, 138. Conscious but con- 
fused mentally; complains of severe headache and "I want to go home." 
Bleeding from left ear has ceased; otoscopic examination reveals a large 
laceration of posterior portion of left tympanic membrane. No aphasia 
nor weakness of right side of body. Pupils equal and react normally. Re- 
flexes: knee-jerks — right exaggerated; right exhaustible ankle clonus and 
right Babinski ; abdominal reflexes present and equal. Fundi — retinal veins 
markedly dilated; both optic disks blurred with edema, though their tem- 
poral margins can still be observed and therefore no measurable swelling or 
papilledema. Lumbar puncture — clear cerebrospinal fluid but under very 
high pressure (approximately 20 mm.). 

Treatment. — A left subtemporal decompression and drainage was now 
advised in the belief that the patient would not be able to absorb the cerebral 
edema normally and in the knowledge that the intracranial pressure was 
daily becoming higher and thus the danger of an acute medullary compres- 
sion and edema was to be feared, — therefore it should be anticipated and 
prevented if possible. 

Operation (June 18, 1915 — 8 days after admission). — Left subtem- 
poral decompression : usual vertical incision, bone removed and no compli- 
cations. Dura very tense and bluish in areas ; upon incising it, bloody cere- 
brospinal fluid spurted to a height of 8 inches and continued for at least 
five seconds. Upon enlarging dural opening, much bloody cerebrospinal 
fluid and many dark blood clots extruded. The "wet" edematous cortex 
tended to protrude and finally ruptured at one point beneath the Syl- 
vian fissure; this cerebral tension was so great that a ventricle puncture 
was performed but only a small amount of clear cerebrospinal fluid escaped 
— therefore, the intracranial pressure was due to cerebral edema and to 
hemorrhage rather than to a blockage of the ventricles. A large amount of 
bloody cerebrospinal fluid escaped but the cortex was still bulging at the end 
of the operation. (A bilateral decompression and drainage was considered 
but it was finally decided to wait in the hope that this one decompression 






ACUTE BRAIN INJURIES 



255 



would be sufficient to lessen the intracranial pressure satisfactorily. ) Usual 
closure with 2 drains of rubber tissue inserted. Duration, 65 minutes. 

Post -operative Notes. — Uneventful operative recovery, although for 3 
weeks following the operation the patient was in a confused mental state 
so that it was necessary to have him closely watched; incision healed 
per primam. 

Examination at discharge (38 days after admission and 30 days after 
operation). — Temperature, 98.6° ; pulse, 74; respiration, 18; blood-pressure, 
130. Perfectly conscious and rational now, though patient is in a rather 
unstable condition emotionally, saying, "I am so homesick and sad." De- 
compression wound bulging but not so tense as one week ago when the 
patient was slightly irrational. Impairment of hearing of left ear — bone 
conduction being greater than air conduction. Pupils equal and react nor- 
mally. Reflexes very active 
but otherwise negative. 
Fundi — retinal veins en- 
larged; nasal margins of 
both optic disks indistinct 
and obscured by edema. 
X-ray (Doctor A. J. Quim- 
by) — "bony defect only of 
decompression dem- 
onstrated" (Fig 69). 

Treatment. — Patient was 
advised to remain at home 
quietly and not to work for a 
period of at least 3 months. 

Examination (September 
10, 1916—15 months after 
injury). — No complaints; 
works daily in his old posi- 
tion. Decompression area de- 
pressed; pulsates normally. 

Hearing of left ear less acute than right; bone conduction equals air con- 
duction. Reflexes active but otherwise negative. Fundi negative. 

Last Examination (September 22, 1918 — 39 months after injury). — Xo 
complaints and is still working in the same place. No impairment of hear- 
ing of the left ear can be ascertained; otoscopic examination negative. Re- 
flexes active but otherwise negative. Fundi negative. The operative area is 
"sunken in," as shown by the photograph (Fig. 70). 

Remarks. — It would undoubtedly have been better surgical judgment to 
have operated earlier upon this patient, but it was hoped after the shock of 
the injury had disappeared that the patient could recover without an 
operation being necessary; it was doubted at the time of the operation 
if the patient would entirely recover ultimately — that is, be as normal an 
individual after the injury as before it ; apparently he is going to recover 
completely. It was interesting to observe that as long as the intracranial 




Fig. 69. — Oval bony defect of a left subtemporal decompres- 
sion in a patient having a high intracranial pressure due to sub- 
dural and subarachnoid hemorrhages. Excellent recovery. 



256 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






pressure remained high so that the decompression area was bulging and 
tense, just so long was the patient slightly irrational and in a confused 
state mentally and emotionally; when this intracranial pressure became 
less, then the mental condition and emotional instability immediately im- 
proved. Another point worthy of note is the fact that clear cerebrospinal 
fluid was obtained at lumbar puncture seven different times before the 
operation, and yet at operation there were found bloody cerebrospinal fluid 
and many small subdural blood-clots; as has been observed frequently in 
other patients of this series, clear cerebrospinal fluid at lumbar puncture 
does not rule out the possibility of subdural hemorrhage ; in these patients, 
this may be due to a blockage of the subarachnoid space at the foramen 

magnum, but this seems very im- 
probable as the danger of a medul- 
lary compression would then be very 
great indeed. 

The operation was also delayed 
for several days longer than it should 
have been in the belief and hope that 
the repeated daily lumbar punctures 
and withdrawal of 15 to 20 c.c. of 
cerebrospinal fluid each time would 
so lessen the increased intracranial 
pressure that it would be unnecessary 
to perform a subtemporal decompres- 
sion and drainage; the relief, how- 
ever, was a temporary one — not last- 
ing longer than 6 to 8 hours after the 
withdrawal of the fluid, and it is a 
mistake in these patients having high 
intracranial pressure to attempt to 
lower it by the method of lumbar 
puncture ; besides, there is a defi- 
nite danger of inducing an acute medullary compression in these patients 
having high intracranial pressure — if over 15 mm., as registered by the 
spinal mercurial manometer. After it was ascertained that the intra- 
dural pressure was very high and upon making a small opening in the 
dura the underlying cortex had tended to protrude, it would have been 
better surgical judgment if then, through this small dural opening a 
ventricle puncture needle had been used to tap the ventricle and in this 
manner the cerebrospinal fluid had been permitted to escape ; thus, the 
intradural pressure would have been so lessened that it would have been 
possible to enlarge the dural opening widely and there would not have 
been any danger of the underlying cortex being damaged or ruptured, as, 
unfortunately, occurred in this patient; it being the temporo-sphenoidal 
lobe, however, naturally there appeared no clinical signs of its presence. 

Case 46. — Acute severe brain injury ; signs of an increasingly high intra- 
cranial pressure associated with subdural and cortical hemorrhage. Right 
subtemporal decompression and drainage. Excellent recovery. 




Fig. 70. — Vertical scar of left subtemporal decom- 
pression (exposed by brushing apart the hair) three 
years after the operation. The depression of the ope- 
rative area indicates the complete lowering of the 
intracranial pressure to normal. 



ACUTE BRAIN INJURIES 257 

No. 526. — Joseph. Thirty-six years. White. Single. Laborer. Italy. 

Admitted March 1, 1917, Polyclinic Hospital. 

Operation March 8, 1917 — 7 days after injury. Right subtemporal 
decompression. 

Discharged April 4, 1917 — 27 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was struck by an 
automobile; immediate loss of consciousness; brought to the hospital in 
the automobile. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 97.4° ; pulse, 110 ; respiration, 32 ; blood-pressure, 120. Semiconscious 
and in severe shock. Profuse bleeding from left ear ; extensive ecchymosis 
of left mastoid area. On account of the severe shock, patient was not 
examined thoroughly at this time. 

Treatment. — Expectant palliative ; vigorous anti-shock measures 
instituted. 

Examination (48 hours after injury). — Temperature 99.2°; pulse, 88; 
respiration, 24 ; blood-pressure, 128. Definite general improvement. Stupor- 
ous, but when aroused very restless and irritable. Bleeding from left ear 
has ceased; otoscopic examination reveals an extensive laceration of entire 
posterior portion of left tympanic membrane. Pupils — right contracted 
and much smaller than left ; sluggish reaction to light. Reflexes — knee-jerks 
exaggerated, left greater than right; suggestive left Babinski; abdominal 
reflexes both depressed, left possibly more than right. Fundi — retinal veins 
enlarged with distinct blurring of nasal margins of both optic disks. Lumbar 
puncture could not] be performed as patient was so restless and difficult to 
manage that it was feared the needle might be broken unless an anesthetic was 
administered, and this was not thought advisable. 

Treatment. — Expectant palliative; patient seemed to improve during 
the following six days. 

Examination (7 days after admission). — Temperature. 100.4°; pulse, 
52 ; respiration, 14 ; blood-pressure, 134. Patient has become more stuporous 
during last 24 hours. Pupils equal and react normally, though slightly 
sluggish ; at times, right pupil much smaller than left. Reflexes — knee-jerks 
exaggerated, left more than right ; left Babinski ; abdominal reflexes — left 
can scarcely be obtained. Fundi — retinal veins tortuous and engorged ; 
definite papilledema of both disks — edematous blurring and obscuration 
of both nasal and temporal halves of optic disks having a measurable swelling 
of 3 D. — that is, the condition of "choked disks." Lumbar puncture — 
"bloody cerebrospinal fluid under extreme pressure (45 mm.) !! 

Treatment. — An immediate right subtemporal decompression advised 
at this time as the signs of increasing intracranial pressure were becoming 
more and more extreme, and thus showing that the patient could not absorb 
the intracranial hemorrhage and edema by the natural means of absorption. 
Operation (7 days after admission). — Right subtemporal decompression : 
usual incision, bone removed and no complications. Dura very tense and 
bluish; upon incising it, free blood spurted under high pressure, revealing 



258 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






! 



a very ' * wet, ' ' tense, swollen cortex in which there were numerous punctate 
hemorrhages. Cortex protruded, but owing to the rapid loss of cerebrospinal 
fluid it receded before the end of the operation and pulsated almost normally. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 45 minutes. 
Post-operative Notes. — Pulse was 100 at end of operation, but it became 
86 within two hours; it was noticed at this time that the left pupil was 
markedly contracted and very much smaller than right, and it was feared 
that possibly a hemorrhage had also occurred over the left hemisphere; he 
was, therefore, carefully watched during the day for any developing signs, 
but within 10 hours after operation the pupils were equal, the pulse was 72, 

and there were no signs of paralysis 
nor convulsions ; mentality was also 
clear. Incision healed per primam. 
Examination at discharge (34 
days after injury and 27 days after 
operation). — Temperature, 99° ; 
pulse, 76; respiration, 20; blood- 
pressure, 140. No complaints ex- 
cept slight dizziness and general 
weakness. Definite impairment of 
hearing of left ear can be demon- 
strated objectively, but patient is 
apparently not aware of it; oto- 
scopic examination reveals a large 
tear of the posterior portion of left 
tympanic membrane ; bone conduc- 
tion greater than air conduction; 
slight left mastoid ecchymosis per- 
sists. Decompression wound has 

Fig. 71.— Eighteen months after a right subtemporal entirely healed ; bulges slightly 

decompression to relieve an extreme intracranial pressure -, -, , -.-. t% 'i 

of 45 mm., as registered by the spinal mercurial mano- and pUlSatCS normally. JTUpilS 

meter and due to an extensive subdural hemorrhage and orn , Q i nnrl Toant Tinrwallv "RoAoypo 

an extreme cerebral edema. Recovery has been excellent, cqildl clllU. iCdLb liuiliictliy . xveiit^X-ek 

active but otherwise negative. 
Fundi — retinal veins enlarged; slight edematous haziness along the nasal 
margins of both optic disks. 

Examination (September 10, 1917 — 6 months after injury). — No com- 
plaints ; works daily. Decompression area slightly depressed ; normal pulsa- 
tion. Reflexes negative. Fundi negative. Hearing of left ear still im- 
paired — bone conduction being greater than air conduction. 

Last Examination (September 22, 1918 — 18 months after injury). — 
Occasional headache at times, but feels well and strong ; ' ' cannot drink any 
more as I become intoxicated very easily. ' ' Decompression site sunken in ; 
slight pulsation still observed (Fig. 71). Reflexes negative. Fundi nega- 
tive. Hearing of left ear impaired ; bone conduction greater than air con- 
duction; otoscopic examination reveals small opening in posterior half of 
left tympanic membrane. 

Remarks. — At the time of the operation it was thought that the decom- 
pression should have been performed 2 or 3 days earlier at least, and it was 




ACUTE BRAIN INJURIES 259 

feared that the patient might not regain his normal condition mentally and 
emotionally as before the injury ; it would undoubtedly have been wiser to 
have operated earlier, and yet it was hoped that by waiting, the operation 
would not be necessary j instead of the intracranial pressure being lessened by 
the expectant palliative method, the signs of increasing pressure became more 
and more marked, particularly in the fundi, and when this observation was 
confirmed more accurately by a measurement of the pressure of the cerebro- 
spinal fluid at lumbar puncture, it was forcefully emphasized that no further 
delay should be permitted and the operation of subtemporal decompression 
and drainage was immediately performed. The numerous punctate hemor- 
rhages throughout the cortex made me feel at the time of the operation that 
this patient could never regain his former normality — it seemed incredible 
that these small cortical hemorrhages would not damage the patient and im- 
pair him both mentally, physically, and especially emotionally ; and yet one 
and a half years following the operation, the patient is practically a normal 
man — possibly a little less stable emotionally, but otherwise well. The excel- 
lent recoveries obtained in similar patients who have been treated by the same 
method would indicate that the brain is capable of absorbing small punctate 
hemorrhages with little or no ultimate impairment — at least to be demon- 
strated clinically, and that this is possible chiefly because the increased intra- 
cranial pressure has been lowered by the operation which facilitates the 
natural absorption of these cortical hemorrhages. It is remarkable how 
patients having so many small hemorrhages in the cortex that the brain 
has almost the appearance of liver or spleen tissue at operation, and yet the 
ultimate recovery may be excellent, although usually associated with a 
definite emotional instability in these severe cases. 

The almost immediate disappearance, following operation, of the con- 
tracted right pupil and the increased deep reflexes of the left side, including 
a suggestive left Babinski, illustrates the effectiveness of the right sub- 
temporal decompression and drainage in diminishing the right cortical irrita- 
tive and compressive factors ; a left subtemporal decompression would have 
been performed immediately after the first operation if the signs pointing to 
a left cortical lesion had not quickly disappeared. It is only in rare cases of 
brain injuries that a bilateral decompression and drainage is necessary, 
and that can be usually decided at the time of the first operation, although in 
some doubtful cases it may be necessary to wait a period of hours or even 
days; naturally, if the one operation is considered sufficient for the relief 
of the increased intracranial pressure, the second operation should be 
avoided if possible. As in this patient having an extreme intracranial 
pressure, even if the signs had pointed to a lesion of the left hemisphere, 
yet it would have been better surgical judgment to have performed a right 
decompression first and then if necessary a left decompression later — thereby 
avoiding cerebral damage. 

The ultimate recovery of the hearing is the usual result in these patients 
when the impairment is limited to the middle ear alone and chiefly to one 
of laceration of the tympanic membrane ; these lacerations usually heal 
within the period of one year at most when the air conduction quickly equals 
that of bone conduction, and within several months the air conduction 



26o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



is greater than bone conduction, as it normally should be. It is only when 
the ossicular transmitting mechanism of the middle ear is damaged by an 
adjacent fracture or the internal ear or the auditory nerve itself is impaired 
that the marked loss of hearing is permanent. Although no cerebro- 
spinal fluid is observed in the discharge of the ear, yet there is frequently 
a fracture of the adjacent bone, and I think this is true of many patients 
where only blood is discharged from the ear — a fracture of the skull is pres- 
ent, although this opinion cannot be stated with certainty at the time unless 
confirmed by rontgenograms, operation or autopsy. 

Case 47. — Acute severe brain injury ; signs of high intracranial pressure 
associated with extradural and subdural hemorrhage with brain laceration. 
Left subtemporal decompression and drainage. Excellent recovery. 

No. 776. — John. Thirty-three years. White. Single. Barkeeper. U. S. 

Admitted February 11, 1917, Polyclinic Hospital. 

Operation February 19, 1917 — 8 days after injury. Left subtemporal 
decompression and drainage. 

Discharged March 19, 1917 — 30 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While walking along the pavement near the gutter, 
patient was struck by an automobile which had run ' ' amuck ' ' ; immediate 
loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 99.4°; pulse, 66; respiration, 16; blood-pressure, 142. Semiconscious 
and could be aroused by firm supra-orbital pressure ; vomited profusely 
during the examination — almost of projectile type. Extensive hematoma 
over left parietal bone. No bleeding from nose, mouth or ears ; no mastoid 
ecchymoses. Pupils — left pupil dilated and reacts sluggishly to light. Re- 
flexes — knee-jerks exaggerated but equal; no ankle clonus nor Babinski; 
abdominal reflexes depressed but equal. Fundi — retinal veins enlarged; 
nasal margins of both optic disks blurred and indistinct, while nasal 
half of left optic disk slightly obscured by edema. Lumbar puncture — 
bloody cerebrospinal fluid under an increased pressure (14 mm.) ; 2 ounces 
were allowed to escape slowly and under careful observation of the pulse. 

Treatment. — Expectant palliative ; it was hoped that the patient would be 
able "to take care of" this increased intracranial pressure by the natural 
means of absorption and thus an operation be avoided. 

Examination (7 days after admission). — Temperature, 100.6° ; pulse, 62 ; 
respiration, 16 ; blood-pressure, 144. Patient not so stuporous as upon admis- 
sion, but the signs of an increasing intracranial pressure have become more 
marked. Patient complains continuously of severe headache when he is 
awake, although he is sleeping most of the time. Pupils — left still larger 
than right and reacts sluggishly to light. Reflexes : knee-jerks exaggerated — 
right more than left ; double ankle clonus and double Babinski ; abdominal 
reflexes cannot be elicited. Fundi: retinal veins very much dilated and 
tortuous ; outlines of both optic disks hazy and obscured and both nasal and 
temporal halves blurred by edema — that is, papilledema in its early stages 
but not of a measurable swelling to the degree of "choked disks." Lum- 



3n 



ACUTE BRAIN INJURIES 261 

bar puncture — bloody cerebrospinal fluid under a high intracranial pres- 
sure (20 mm.). 

Treatment. — An immediate left subtemporal decompression advised. 

Operation (7 days after admission). — Left subtemporal decompression: 
usual incision, bone removed and no complications ; in the temporal muscle 
beneath the temporal fascia, there was much free blood and upon retracting 
the muscle an oblique linear fracture extending downward through the mid- 
dle portion of the squamous bone was exposed. Upon rongeuring away the 
bone, a large extradural blood-clot of one-half inch in thickness was extruded 
through the bony opening; posteriorly, the dura was depressed from the 
bone to a depth of one inch by this blood-clot, which had an extent of 
at least 5 inches. This extradural hemorrhage being evacuated, the bluish 
dura was now incised, allowing considerable subdural hemorrhage to escape 
and also a small quantity of hemorrhagic brain tissue to be extruded under 
high pressure; the cortex had been lacerated just beneath the Sylvian 
fissure ; the adjacent brain tissue was hemorrhagic and had almost the appear- 
ance of liver tissue. On account of the escape of a large amount of 
cerebrospinal fluid and blood, the brain now receded and pulsated normally. 
Usual closure with 2 drains of rubber tissue inserted subdurally, and one 
gauze tape extradurally toward the left mastoid area, which was bleeding 
profusely as if the lateral sinus had been torn ; this packing was sufficient 
to stop the bleeding extradurally. Duration, 70 minutes. 

Post-operative Notes. — Uneventful operative recovery; patient became 
conscious within 18 hours and made an excellent convalescence ; incision 
healed per primam. 

Examination at discharge (38 days after injury and 30 days after 
operation). — Temperature, 98.6°; pulse, 70; respiration, 20; blood-pres- 
sure, 136. Perfectly conscious and rational; sleeps at least 14 hours 
a day. No complaints other than soreness over left side of head. De- 
compression area flush with surrounding scalp ; pulsates normally. Pupils 
equal and react normally. Reflexes very active but otherwise negative. 
Fundi — retinal veins enlarged; nasal margins indistinct and hazy but the 
other details of both optic disks are clear. X-ray (Doctor W. H. Stewart) — 
' ' oval bony defect of left decompression shown ; oblique fracture of left vault 
observed" (Fig. 72). 

Examination (November 6, 1917 — 9 months after injury). — No com- 
plaints other than an occasional headache, " after tending bar all day." 
Reflexes active but otherwise negative. Fundi negative. Decompression area 
slightly depressed but not so much as it should be ; pulsation normal. 

Last Examination (September 10, 1918 — 19 months after injury). — No 
complaints. Decompression site, however, is only slightly depressed; pul- 
sates normally. Reflexes very active but otherwise negative. Fundi negative. 

Remarks. — It would have been better surgical judgment to have advised 
the decompression at least 2 days earlier, but it was hoped that an operation 
would not be necessary, and it was not until a definite papilledema appeared 
and the pressure of the cerebrospinal fluid reached 20 nun. that a decom- 
pression was considered obligatory. 

It would have been better surgical judgment when the intradural pros- 



262 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



sure was ascertained to be extreme after a small dural opening had been 
made, if a lumbar puncture had now been performed and a large amount 
of cerebrospinal fluid carefully withdrawn ; in this manner the intracranial 
pressure could have been greatly lessened so that the dural opening could 
be widely enlarged with little or no danger of the underlying cerebral cortex 
being forced upward through the dural opening and its being ruptured. 
Although no clinical signs of this laceration have appeared in this patient 
following the operation (the affected underlying cortex being the temporo- 
sphenoidal lobe which is a comparatively silent area of the brain, and espe- 
cially the right one), still it is inconceivable that some impairment has not 
occurred, mental or psychical at least, and it is only on account of our crude 
methods of examination that these slight impairments cannot be ascertained. 
The dilated left pupil with sluggish reaction to light was indicative 

of an ipsolateral compressed 
a- ^^H left cerebral cortex, and be- 

ing associated with increased 
jjB deep reflexes of the right side 

mk and possibly greater signs of 

pressure in the left fundus, 
this opinion was greatly con- 
firmed and then proven at 
operation. 

Although this patient has 
apparently entirely recov- 
ered his former good health, 
yet it would undoubtedly 
have been wiser to have oper- 
ated several days before in 
order to assure a greater re- 
covery of normal function — 
mentally, physically and 
emotionally, and also to have 
lessened the danger of- an 
acute medullary compression and even edema itself. This is the type of 
patient frequently observed who can endure the increased intracranial 
pressure for a number of days and even several weeks, and then finally and 
suddenly succumbs to an acute medullary compression and edema. The 
value of careful, daily and even hourly, examinations of the fundi and also 
but of less value, of the pulse, respiration and blood-pressure and then the 
most accurate means of ascertaining the intracranial pressure by means of 
the spinal mercurial manometer should be utilized, and thus the onset of 
medullary compression be avoided — as it usually can be in these patients. 
B. Bilateral decompression. 

Case 48. — Acute severe brain injury; signs of extreme intracranial 
pressure associated with subdural and intracerebral hemorrhages. Bilateral 
decompression and drainage. Excellent recovery. 

No. 048. — Frank. Thirty-two years. White. Married. Mechanic. U. S. 




Fig. 72. — Oblique linear fracture of posterior portion of left 
parietal bone extending into the upper posterior portion of left 
decompression opening: two silver clips are disclosed at the 
lower margin of the decompression and are clamping the left 
middle meningeal artery. Excellent recovery. 



ACUTE BRAIN INJURIES 263 

Admitted March 5, 1913, Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Operations March 6 and 7, 1913 — 33 and 59 hours, respectively, 
after injury. Bilateral decompression and drainage. 

Discharged April 12, 1913 — 25 days after second operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was struck by an auto- 
mobile ; unconscious for several minutes but was then able to arise and walk 
to the curb, where he sat down ; several minutes later a policeman arrested 
him as a disorderly character ; taken to the station house, and as the patient 
was unable to talk, he was designated a "foreigner" on the register. Four 
hours later, he was found semiconscious in his cell and was then transferred 
to the hospital in the ambulance. 

Examination upon admission (5 hours after injury). — Temperature, 
101° ; pulse, 68 ; respiration, 18 • blood-pressure, 150. Well-developed and 
nourished. Semiconscious but can be aroused easily by supraorbital pres- 
sure. Motor aphasia complete — unable to speak or utter a sound. Bleeding 
from nose; both orbits ecchymosed — right more than left. Bleeding pro- 
fusely from left ear ; left mastoid ecchymosis. Pupils contracted equally and 
react to light normally. Reflexes : patellar — right greater than left ; right 
Babinski ; right abdominal reflex could not be elicited. Fundi — retinal veins 
full; nasal margins blurred with edema but temporal margins and nasal 
halves clear and distinct. Lumbar puncture — bloody cerebrospinal fluid 
under increased pressure (approximately 14 mm.). 

Treatment. — Expectant palliative. 

Examination (24 hours after admission). — Temperature, 100.4°; pulse, 
62 ; respiration, 16 ; blood-pressure, 160. Patient remains semiconscious ; 
unable to speak a word. Physical condition practically the same as at the 
preceding examination, except that the ophthalmoscope reveals the retinal 
veins dilated and the nasal halves of both optic disks obscured by edema. 
Lumbar puncture — bloody cerebrospinal fluid under increased pressure 
(approximately 18 mm.). 

Treatment. — A left subtemporal decompression now advised in order 
to prevent the onset of a definite medullary compression, and also to expose 
the motor speech centre in the posterior portion of the third left frontal 
convolution through the anterior portion of the left decompression opening. 
(Patient being right-handed — his parents and grandparents also being right- 
handed — therefore his motor speech centre was in the left cerebral cortex.^ 

First Operation (March 6, 1913 — 28 hours after admission). — Left sub- 
temporal decompression : usual vertical incision, bone removed and no com- 
plications ; much free blood among the fibres of temporal muscle beneath the 
temporal fascia, therefore a fracture of the underlying bone, and this 
observation was confirmed by exposing 2 irregular lines of fracture in the 
squamous portion of the temporal bone. Dura very tense and bluish ; upon 
incising it large dark clots, the size of olives, welled up through dural 
opening, and upon enlarging dnral opening, these dark elots could bo seen 
protruding through a laceration of the posterior portion of the third left 



264 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

frontal convolution — that is, the motor speech area. Brain very tense and 
"water-logged" with many punctate hemorrhages throughout the cortex, 
which tended to protrude; as very little cerebrospinal fluid escaped, the 
cortex, which continued to remain tense, scarcely pulsated, so that by the 
end of the operation the brain had not receded as it usually does. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 1 hour. 

Post -operative Notes. — There was little or no improvement in the con- 
dition of the patient within 24 hours after operation; he remained in a 
semiconscious condition with a pulse of 62 and a respiration of 16, and as 
the decompression area was so tense and bulging that it did not pulsate, 
it was decided to perform a right subtemporal decompression. 

Second Operation (26 hours after first operation and 54 hours after- 
admission). — Right subtemporal decompression: usual vertical incision, 
bone removed and no complications. Dura very tense and only slightly 
bluish; upon incising it, merely blood-tinged cerebrospinal fluid escaped, 
allowing the "wet" edematous cortex to pulsate. No subdural clots found, 
but at the end of the operation as the result of the escape of much blood- - 
tinged cerebrospinal fluid, the cortex lessened its protrusion and pulsated 
normally. Usual closure with 2 drains of rubber tissue inserted. The left 
subtemporal decompression area remained so tense and bulging that it was 
thought advisable to reopen the incision, which was done, and a large 
subdural clot welled through the dural opening and also small clots, the 
size of cherries, were extruded through the cortex of the motor speech area ; 
upon removing these clots, the cortex became less tense and the incision 
was now closed in usual manner with 2 drains of rubber tissue inserted. 
Duration, 80 minutes. 

Post-operative Notes. — On the second day, patient was still unable to 
talk, but he was conscious and would shake hands with those whom he recog- 
nized as his friends. Hearing apparently impaired. Pupils equal and react 
normally. Reflexes — patellar equally exaggerated and a suggestive double 
Babinski. Fundi — retinal veins dilated while the nasal margins of both 
optic disks are still obscured. On the fifteenth day after operation, patient 
was able to say several words intelligibly. 

Examination at discharge (27 days after admission and 26 days after 
first operation). — Temperature, 98.6°; pulse, 70; respiration, 18; blood- 
pressure, 142. Perfectly conscious with no complaints ; can talk fairly well 
in a hesitating manner. Hearing of left ear impaired — bone conduction 
being greater than air conduction; otoscopic examination reveals a lacera- 
tion of the left tympanic membrane through its inferior portion. Pupils 
equal and react normally. Reflexes — very active but otherise negative. 
Fundi — retinal vessels slightly enlarged but no edema of the optic disks. 
Decompression areas tense but not bulging. X-ray (Doctor A. J. Quimby) — 
"the bilateral decompression openings are clearly demonstrated" (Fig. 73). 

Examination (June 7, 1914 — 3 months after injury). — No complaints; 
patient went to work 41 days after operation and is now working daily as 
a chauffeur. Hearing of left ear still impaired. Reflexes active but otherwise 
negative. Fundi negative. No impairment of speech apparently, except 
for "catch" and test phrases, such as "truly rural"; "around the rugged 



ACUTE BRAIN INJURIES 



265 



rock the ragged rascal ran"; "the third red riding artillery brigade," 
etc., when the patient slurs the words occasionally. 

Examination (September 20, 1915 — 30 months after injury). — No com- 
plaints; patient, however, is becoming alcoholic and at this examination 
is slightly intoxicated. Hearing of left ear has improved and bone conduc- 
tion is no longer greater than air conduction. Reflexes active but otherwise 
negative. Fundi negative. Speech was not tested at this examination on 
account of the patient's emotional instability due to alcohol. Decompression 
areas depressed and pulsating normally. 

Examination (September 20, 1917 — 53 months after injury). — Patient 
has just returned from France, where he has been driving an ambulance 
during the past year. No complaints and ' ' equal to three Germans. ■ ' Alco- 
holic no longer. No impair- 
ment of hearing of left ear 
can be elicited. Slight im- 
pairment of speech can still 
be ascertained by test 
phrases only. Hearing nega- 
tive. Reflexes active but 
otherwise negative. Fundi 
negative. 

Last Examination (Sep- 
tember 28, 1918—65 months 
after injury) . — P a t i e n t 
writes from France that he 
is " as well as ever. ' ' 

Bern arks . — In these 
patients having a high intra- 
cranial pressure and when 
one decompression does not 
lessen the intracranial pres- 
sure markedly so that the 
brain can pulsate normally, 

then a second decompression should be performed immediately if the general 
condition of the patient warrants it ; if the general condition of the patient, 
however, is such that an immediate second operation would be too dangerous, 
then it would be advisable to wait for a period of from 24 to 48 hours before 
attempting it. These bilateral decompressions are usually necessary if the 
brain is "water-logged" and yet "dry" — that is, a swollen brain but very 
little cerebrospinal fluid escapes at the time of the first operation and there- 
fore rendering a second operation necessary. The recovery of speech in a 
patient whose motor speech area was accurately observed at operation to be 
lacerated and through which large blood-clots' were extruded, tends to con- 
firm the belief as formed from similar lesions in other patients, that The 
impairment of speech in these patients must be due to a local compression 
of the cortical cells due to blood-clot and edema rather than one of actual 
destruction of the cells of motor speech — otherwise there would be no return 
of function. 




Fig. 73. — Lateral roentgenogram showing the bony 
defects of the bilateral decompression operation to lower an 
extreme intracranial pressure due to subdural and intra- 
cerebral hemorrhages. Excellent recovery. Note the 
prominent external occipital protuberance. 



266 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

This patient has been examined by me repeatedly since the operation 
and he is apparently normal mentally, emotionally and physically. It is a 
remarkable case — not only on account of the recovery of his life but the 
complete return of his former normal condition ; at the time of the operation, 
when large dark clots were seen welling up through the substance of the 
brain, it was not conceived possible that this patient could return_to his 
former normality. This case illustrates the advisability of performing 
a bilateral operation when it seems improbable that the one decompression 
will be sufficient to lessen the increased intracranial pressure entirely; it 
is not so much a question of hemorrhage or edema (that is, an excess amount 
of cerebrospinal fluid), but rather a question of the amount of increased 
intracranial pressure; whether it be due to hemorrhage or edema, it matters 
not — the chief object of the treatment being to lessen the pressure. 

It is interesting to note that frequently the laceration of the brain and 
the intracranial hemorrhage may be found in one hemisphere, and yet 
all of the signs obtained at the examinations point to the other cerebral 
hemisphere as being the one greater damaged ; it is difficult to explain this 
apparent paradox — unless due to contre-coup or to a subcortical hemorrhage, 
which is not ascertained when the bilateral decompression is performed ; as 
the condition, however, frequently improves so quickly following operation, 
this latter explanation is only probable. It is possible that the greater com- 
pression being over one hemisphere, in some manner forces the other hemi- 
sphere against the overlying vault of the skull and thus produces the clinical 
signs of a greater impairment of the other hemisphere. The intracranial 
lesions in patients of this character are so multiple that it is most difficult 
to explain satisfactorily the causes of all of the clinical signs merely from 
the observations at the two operations which reveal only comparatively 
small portions of the entire brain itself. When the clinical signs are very 
confusing in these patients, it is better surgical judgment to perform a right 
subtemporal decompression first and then the left subtemporal decompression 
would be easier technically and of less danger to the underlying cere- 
bral cortex. 

Case 49. — Acute severe brain injury; signs of extreme intracranial 
pressure ; subdural and intracerebral hemorrhage. Bilateral decom- 
pression and drainage. Recovery. 

No. 079.— Andrew. Twenty-five years. White. Single. Clerk. U. S. 

Admitted November 30, 1913, Muhlenburg Hospital, Plainfield, N. J. 
Referred by Doctor B. Yan D. Hedges. 

Operations — December 3 and 16, 1913 — 6 and 22 days, respectively, 
after injury. Bilateral decompression and drainage. 

Discharged February 2, 1914 — 43 days after second operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Three days ago, while patient was riding a motor- 
cycle, he collided with a stone wall ; immediate loss of consciousness ; brought 
to the hospital immediately in profound shock, unconscious and has re- 
mained unconscious; profuse bleeding from left ear. 

Treatment. — Expectant palliative. 



ACUTE BRAIN INJURIES 267 

Examination (3 days after admission). — In consultation with Doctor 
Hedges : temperature, 100.6° ; pulse, 78 ; respiration, 20; blood-pressure, 144. 
Well developed and nourished. Unconscious and cannot be aroused. In- 
continence of urine and feces. Both orbits ecchymotic and bilateral sub- 
conjunctival hemorrhages. Dry blood in left auditory canal; left mastoid 
ecchymosis. Marked edema and apparent tenderness over left squamous 
region. Pupils equal and react to light normally. Reflexes: patellar exag- 
gerated, especially right; bilateral Babinski and ankle clonus; abdominal 
reflexes present and equal. Fundi : retinal veins dilated ; edematous blurring 
of entire nasal halves of both optic disks. Lumbar puncture — cerebrospinal 
fluid bloody and under very high pressure (approximately 20 mm.). 

Treatment. — An immediate left subtemporal decompression advised to 
lessen the high intracranial pressure. 

First Operation (3 days after admission). — Left subtemporal decom- 
pression : usual vertical incision, bone removed and no complications ; much 
free blood and ecchymosis of temporal muscle beneath the temporal fascia 
and thus indicating a fracture of the underlying bone ; this observation was 
confirmed upon retracting the fibres of the temporal muscles and exposing a 
horizontal linear fracture of the squamous portion of left temporal bone, ex- 
tending forward and backward beyond the margins of the decompression 
opening. Small extradural clot evacuated ; dura very tense and, upon incis- 
ing it, bloody cerebrospinal fluid spurted to a height of 8-10 inches for a 
period of one minute. Upon enlarging dural opening, the ' ' wet ' ' edematous 
cortex tended to protrude under high pressure, owing to the rapid escape of 
much cerebrospinal fluid and blood ; the ' ' sweating ' ' of the arachnoid was 
very marked, so that the brain became less tense before the end of the opera- 
tion. Just below the Sylvian fissure, dark-clotted blood of the consistency 
of currant jelly welled out through a cortical laceration of 2 cm. in length 
and small blood-clots continued to extrude during the operation. Numerous 
punctate hemorrhages throughout the cortex. Usual closure with 2 drains of 
rubber tissue inserted. Duration, 1 hour. Post-operative notes : decompres- 
sion area remained unusually tense, and as the patient did not become entirely 
conscious but remained delirious and stuporous, I examined the patient for 
the second time on December 16, 1913 — 13 days after the first operation : 
the decompression area was very tense — so much so that it could not 
pulsate ; the left reflexes were greater than the right, a left Babinski and 
left ankle clonus were present, while the fundi showed a blurring of the nasal 
halves of the optic disks and a dilatation of the retinal veins ; therefore, 
as the intracranial pressure was still very high, it was thought advisable to 
perform a similar decompression and drainage upon the other side 
of the head. 

Second Operation (December 16, 1913 — 13 days after the first opera- 
tion). — Right subtemporal decompression: usual vertical incision, bone 
removed and no complications ; temporal muscle beneath the temporal fascia 
ecchymosed and beneath it in the squamous portion of the temporal bone were 
2 irregular fractures extending downward into the base. Dura very tense 
and bluish ; upon incising it, blood-tinged cerebrospinal fluid spurted under 
high pressure, and upon enlarging dural opening a very "wet" edematous 



268 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




cortex with many punctate hemorrhages was exposed ; it tended to protrude 
but did not rupture, and at the end of the operation the brain pulsated 
normally, owing to the loss of much cerebrospinal fluid. Usual closure with 
2 drains of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery : patient began to 
improve immediately after the operation ; became conscious upon the second 
day, and although he remained mentally confused for almost a week, yet 
that condition gradually lessened so that the operative recovery was excel- 
lent; the Babinski reflex could not be obtained for the first time on the 16th 
day after operation. 

Examination at discharge (62 days after admission). — Temperature, 

98.8° ; pulse, 70 ; respiration, 
18 ; blood-pressure, 13 6. 
Patient feels well ; occasional 
headache when stooping ; 
rather difficult for patient to 
think consecutively. ' ' Can 't 
concentrate my thoughts"; 
perseveration of words at 
times. Definite impairment 
of hearing of both ears — 
bone conduction being 
greater than air conduction ; 
otoscopic examination re- 
veals a healing laceration of 
the posterior portion of left 
tympanic membrane, whereas 
the right tympanic meim 
brane is intact, but thickened 
and retracted. Patient be> 
comes fatigued after any ex r 
ertion. Decompression areas 
slightly depressed ; normal 
pulsation. Pupils equal and 
react normally. Reflexes 
very active but otherwise negative. Fundi : retinal veins of normal size ; 
no edema of optic disks but along the nasal margins and in the physiological 
cups there is a small amount of new tissue formation — that is, a very mild 
degree of secondary optic atrophy due to the former high intracranial 
pressure being prolonged over a period of weeks. 

Examination (June 7, 1914 — 7 months after injury). — No serious com- 
plaints ; patient is at work daily in an office where it is not strenuous. Talks 
rather slowly, with a definite retardation of mentality. Easily fatigued 
and always before the end of the day. Both decompression areas depressed ; 
normal pulsation. Hearing of left ear impaired ; bone conduction is greater 
than air conduction. Reflexes active but otherwise negative. Fundi : no 
edema of margins of optic disks but a slight amount of new tissue formation 
along the nasal margins; retinal veins of normal size. X-ray (Doctor A. J r 




Fig. 74. — Bony defects of bilateral decompression operation 
clearly shown; note the greater removal of bone of the left de- 
compression. The high intracranial pressure due to subdural 
and intracerebral hemorrhages successfully lowered. Excellent 
recovery. 



ACUTE BRAIN INJURIES 



269 



Quimby) — "the areas of bony decompression revealed; no lines of fracture 
observed" (Fig. 74). 

Examination (June 10, 1916 — 31 months after injury). — There is still 
a definite retardation mentally and a marked slowness of speech; easily 
fatigued so that patient is unable to do hard physical work for a number 
of hours. Patient, however, works daily and is able to support himself. 
Hearing of left ear still impaired ; right ear almost normal. Reflexes active 
but otherwise negative. Fundi, the same as at preceding examination. 

Examination (May 10, 1918 — 54 months after injury). — Patient has 
just returned from an army cantonment where he has been chauffeur ; he 
was able to perform this work satisfactorily, but succeeded in obtaining his 
discharge in order to enlist in the regular army and desires a certificate 
of good health. No complaints. "I feel better and stronger now than 
at any time since the injury. ' ' Both de- 
compression areas depressed; difficult 
to elicit pulsation by palpation. Hear- 
ing of left ear still impaired; bone 
conduction is greater than air conduc- 
tion. Reflexes active but otherwise 
negative. Fundi : retinal veins of nor- 
mal size; nasal margins of both optic 
disks irregular from new tissue forma- 
tion. Limited service in the army was 
considered advisable. A photograph 
was taken May 8, 1918 (Fig. 75). 

Remarks. — It is to be regretted that 
the bilateral decompression was not per- 
formed at the time of the first operation 
— that is, 3 days after the injury; it 
was not advised at that time, however, 
as it was thought that the one decom- 
pression would be sufficient. This 
period of high, increased pressure per- 
sisting almost 3 weeks was sufficient to 

impair the cortical cells functionally, at least for a period of years, and 
possibty permanently. This case illustrates the necessity of an early lessen- 
ing of the increased intracranial pressure as soon as possible after the initial 
shock of the head injury has disappeared — not only as a means of possibly 
saving the life of the individual, but, very important, to obtain as nor- 
mal an individual as before the injury, or at least to approximate the 
former normality. 

The permanent impairment of hearing of the left ear and referable to 
the middle ear, is undoubtedly due to scar tissue formation and retraction 
of the left tympanic membrane and possibly some impairment of the ossicu- 
lar transmitting mechanism of the left middle ear. As a rule, however. 
the impairment of hearing in these patients referable to the middle ear is of 
temporary duration only — 12 to 18 months, — whereas if the condition has 
been complicated by an otitis media or by an unusual amount of new tissue 




Fig. 75. — This patient had an extreme intra 
cranial pressure due to subdural and intracerebral 
hemorrhages but no fracture of the skull; success- 
fully treated by a bilateral subtemporal decom 
pression and drainage. 



270 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

formation in the middle ear and if the laceration of the tympanic membrane 
should not be repaired perfectly, then there is always a more or less degree 
of deafness resulting. 

If it had been realized in this patient that the increased intracranial 
pressure was so extreme, then undoubtedly the first operation would have 
been performed upon the right side of the head for fear of a possible injury 
to the motor speech area if a left decompression should be performed ; how- 
ever, as the clinical signs of this patient indicated a greater lesion of the left 
cerebral hemisphere and since the intracranial pressure could not then be so 
accurately estimated as it can be now, the left subtemporal decompression 
and drainage was performed first, and fortunately no operative damage 
occurred; it was unfortunate, however, that an immediate bilateral decom- 
pression was not performed, as it would be now without any hesitation 
under similar conditions of extreme intracranial pressure. These patients 
having such extreme intracranial pressure are rare, but when they do occur 
then the appropriate bilateral decompression and drainage should be per- 
formed ; it seems that strong, well-nourished and well-developed adults be- 
tween 20 and 35 years of age who have greater powers of resistance — 
these are the patients having cranial injuries who frequently develop the 
highest intracranial pressure, and this is naturally explained upon physi- 
ological grounds. 

The indefinite emotional instability of this patient and the vague mental 
retardation as exhibited at a number of the examinations during the past 
5 years are due undoubtedly to this extreme intracranial pressure persist- 
ing acutely for over 3 weeks following the injury, and also to the definite 
damage of the cerebral cortex itself from the punctate hemorrhages, lacera- 
tions and supracortical hemorrhages. This patient, in my opinion, would 
have died unless the cranial operations had been performed, and it is to be 
regretted that they were not performed as early as possible following 
the injury. 

Case 50. — Acute severe brain injury; signs of extreme intracranial 
pressure associated with extradural, subdural, cortical and intracranial 
hemorrhage. Bilateral decompression and drainage. Recovery. 

No. 109. — John. Twenty-seven years. White. Single. Orderly. U. S. 

Admitted February 25, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Operation February 25, 1914 — 2% hours after injury. Bilateral 
decompression and drainage. 

Discharged March 16, 1914 — 20 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — "While intoxicated, patient fell from a taxicab; imme- 
diate loss of consciousness ; brought to the hospital in a taxicab. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 99°; pulse, 66; respiration, 16; blood-pressure, 140. Semiconscious 
upon admission — could be easily aroused and talked incoherently and irrele- 
vantly; within 20 minutes, however, and during the examination, it be- 
came increasingly difficult to arouse patient so that he became profoundly 
unconscious. Contusion over top of head. Profuse bleeding from the nose, 




ACUTE BRAIN INJURIES 271 

but none from mouth or ears. Pupils very small and contracted but equal. 
Reflexes : patellar — left greater than right ; suggestive left Babinski ; abdom- 
inal reflexes cannot be obtained. Fundi — retinal veins dilated ; nasal mar- 
gins of both optic disks blurred by edema. Lumbar puncture — bloody 
cerebrospinal fluid under high pressure (approximately 20 mm.). 

Treatment. — During the examination and within 1 hour later, patient 
became profoundly unconscious, pulse descended to 60, respiration to 14 
and of the Cheyne-Stokes type of irregularity ; a definite left Babinski was 
elicited and the ophthalmoscope revealed an obscuration of the nasal halves 
and also the temporal margins of both optic disks. As the intracranial 
pressure was undoubtedly increasing and very rapidly, an immediate right 
subtemporal decompression was considered advisable. While waiting for 
the operating room to be prepared, Doctor A. J. Quimby made a rontgeno- 
gram which disclosed a 
"linear fracture of the 
frontal bone" (Fig. 76). 

First Operation (2 
hours after admission) . — 
Right subtemporal decom- 
pression : usual vertical in- 
cision, removal of bone and 
no complications. Large 
extradural clot covered the 
lower half of the operative 
field and dark clots — the 
size of English walnuts — 

welled up from the base 6tt%^ 

extradurally. Upon evacu- H- j \^Jk 

ating this extradural 

-1 -1 , 1 -, Fig. 76. — Oblique linear fracture of right frontal bone in a 

nemormage, t n e QUra patient having a very high intracranial pressure due to extra- 

whlVh "hflrl hppn rlpr>rps«prl dural, subdural and intracerebral hemorrhages. Recovery fol- 

W111LI1 IldU ueeil uepiesseu lowing a bilateral subtemporal decompression. 

was very tense and of a 

dark blue tint, and upon incising it, large subdural clots welled up from the 
base. The intradural tension was so high that the underlying cortex, which 
was filled with punctate hemorrhages, ruptured transversely to a length of 
3 inches and even 2 inches in width ; much dark clotted blood extruded from 
this laceration and the entire cortex tended to protrude through the bony 
opening— gauze tape packing being necessary to control the hemorrhage 
coming from the base. Owing to this high cerebral pressure, which appar- 
ently could not be entirely relieved by the unilateral decompression, it was 
considered advisable to perform a similar decompression upon the opposite 
side of the head. Usual closure with 2 drains of rubber tissue inserted. 
Temporary sterile gauze dressing applied. 

Second Operation. — Left subtemporal decompression : usual vertical 
incision, bone removed and no complications. No extradural clot. Dura 
very tense and upon incising it, the hemorrhagic cortex — almost the appear- 
ance of liver tissue — tended to protrude but did not rupture; a small 
amount of blood-tinged cerebrospinal fluid oozed through the dural opening 
but the cortex was so swollen and "water-logged" that the pressure was not 



d 



272 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

greatly lessened by the drainage of this small amonnt of fluid. Cortex 
at end of operation, however, did pulsate but very slightly. Usual closure 
with 2 drains of rubber tissue inserted. Duration, 80 minutes. 

Post-operative Notes. — Patient became conscious 6 hours after operation, 
although he was very much mentally confused and mildly delirious. Twenty- 
four hours later, patient sat up in bed saying ' ' I want to go home, take this 
bandage off " ; the pulse was 64. Five days after operation, in an attempt to 
remove the gauze packing used to control the hemorrhage at the base during 
the operation, the bleeding became very profuse, requiring another gauze 
tape packing to be used. On the tenth day after operation, the sutures were 
all removed and also the gauze packing. Patient has been mildly delirious ; 
it was now ascertained that the patient has been a drug addict and upon his 
receiving the appropriate treatment by Doctor E. S. Bishop for the drug 
addiction the patient began to improve immediately. Incisions healed 
per primam. 

Examination at discharge (21 days after admission). — (Patient trans- 
ferred to Bellevue Hospital at the request of Doctor E. S. Bishop so that 
he could be properly controlled for his drug addiction.) Temperature, 
99.6°; pulse, 68; respiration, 20; blood-pressure, 144. Both decompres- 
sion areas bulge slightly beyond the flush of scalp ; normal pulsation. 
Pupils contracted equally (morphia). Reflexes: patellar very active — left 
being possibly greater than right; suggestive left Babinski; abdominal 
reflexes present and equal. Fundi — retinal veins enlarged ; edematous blur- 
ring of nasal margins of both optic disks, but other details of disks clear 
and distinct. 

Report (September 20, 1916 — 31 months after injury) . — Patient was met 
while at work in another hospital ; is able to do his work, but it is believed 
that he is still a drug addict. Decompression openings did not bulge and 
patient had no complaints referable to the former head injury. 

Last Report (June 16, 1918 — 52 months after injury). — Patient works 
daily as an orderly in the hospital ; no complaints referable to the former 
head injury. Both decompression areas are depressed. Patient admits his 
drug addiction but refuses treatment. 

Remarks. — It is hardly conceivable that a patient having such a severe 
brain injury as this patient could recover so well; especially so, when it 
is remembered that not only was the brain lacerated but that throughout 
the exposed cortex there were so many punctate hemorrhages that it had 
almost the appearance of liver tissue. It merely tends to confirm the opin- 
ion, however, that the danger of brain injuries is not so much due to the 
laceration or hemorrhage in the brain substance as it is the effect of high 
intracranial pressure being permitted to remain during a period of days 
and weeks — not only so far as life itself is concerned, but as to the future 
normality of the patient. It must be remembered also that the part of the 
brain exposed by the decompression operation is merely the temporo- 
sphenoidal lobe, the lower portion of the parietal lobe and at times the 
posterior portion of the contiguous frontal lobe, and that these portions 
of the cortex are, in the right cerebral hemisphere in right-handed individ- 
uals, comparatively "silent" areas, and even in the left cerebral hemi- 



ACUTE BRAIN INJURIES 273 

sphere in right-handed patients, if we exclude the motor speech area in the 
posterior portion of the third left frontal convolution ; any damage to the 
cortex immediately beneath the decompression opening is only ascertained 
clinically with difficulty and by special tests, so that the large area of the 
cerebral cortex, not exposed by the decompression operations, may not be 
in some of these patients injured at all, and yet the area of the cortex, exposed 
at operation may be lacerated and exceedingly hemorrhagic ; frequently at 
autopsies upon patients having had brain injuries and yet no operation 
having been performed, the areas of the cortex most frequently lacerated 
and contused are the temporo-sphenoidal lobes, then the frontal lobes and 
finally the occipital lobes, and in this order of frequency. 

It would have been better judgment surgically if, upon ascertaining that 
the intradural pressure was so extremely high, a lumbar puncture had been 
made and cerebrospinal fluid withdrawn just before the dura at the first 
operation was opened ; in this manner the intradural pressure would have 
lessened and there would have been less risk of the underlying cerebral 
cortex rupturing ; a ventricle puncture might also have been attempted before 
opening the dura widely. Although no clinical signs of this cortical rupture 
persisted, yet it certainly does the brain and the patient no good, and this 
complication technically, whenever possible, should be avoided. 

The small contracted pupils of the patient as observed upon admission 
to the hospital were, at that time, considered as being due to severe cortical 
irritation; the factor of drug-addiction disclosed later may have been the 
cause of these pin-point pupils (as the condition persisted even after the 
discharge of the patient from the hospital), and yet this patient did have 
sufficient cortical irritation to produce this extreme miosis. 

Acute Severe Brain Injuries Associated with a High Intracranial 
Pressure Due to Cerebral Edema Alone and Requiring the Cranial 
Operation of Subtemporal Decompression and Drainage. 

It is this factor of acute cerebral edema (an increased amount of cerebro- 
spinal fluid), which results in varying degree from brain injuries and in 
fact from so many cranial injuries alone, with and without a fracture of the 
skull, that has been so frequently overlooked in the past, and it is this com- 
plication of cerebral edema which makes these injuries such serious ones, both 
in their immediate and remote effects. It is not definitely known whether 
this excess of cerebrospinal fluid is due to its increased secretion or to its 
diminished absorption and excretion, although the latter cause is more 
probably the correct one. 

Even in cranial injuries not more severe than to produce a cerebral 
"concussion" — in many of these patients there is demonstrated a mild 
increase of the pressure of the cerebrospinal fluid, as elicited by careful 
ophthalmoscopic examinations and by the spinal mercurial manometer ; this 
latter test reveals the cerebrospinal fluid clear and of normal eell count, 
whereas the pressure may be increased to 11-12 mm (normal 5-9 mm.) ; these 
patients continue to have headache and the other symptoms and signs of a 
mild increase of the intracranial pressure, until the expectant palliative 
treatment facilitates the gradual absorption of the excess cerebrospinal fluid 
18 



274 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



and then the headaches, etc., cease and there is no longer an increased intra- 
cranial pressure, as revealed by the ophthalmoscope and the spinal mano- 
metric tests — and this is the usual result. Chronic alcoholism and cardio- 
renal diseases as well as any chronic toxemic condition permit and appar- 
ently predispose these patients to the formation of cerebral edema, and the 
prognosis in these patients is always more grave. 

An acute cerebral edema, however, following a brain injury, with and 
without a fracture of the skull, may produce such an increase of the intra- 
cranial pressure that the danger of medullary compression is an imminent 
one. and if extreme or prolonged then the great risk of the onset of acute 
medullary edema — and the death of the patient. The autopsy records 
of these patients disclose such a "wet" edematous condition of the brain and 
of the medulla itself that medullary compression and its end-result, medul- 
lary edema, had resulted ; a fracture of the skull may or may not be present, 
and in some patients the cerebrospinal fluid may be blood-tinged, although 
the amount of blood was so small that it did not increase the intracranial 
pressure to any appreciable degree. It is in this type of patient in whom 
no intracranial hemorrhage nor even a fracture of the skull was demon- 
strated and yet having a high intracranial pressure — these are the patients 
who rarely received the appropriate treatment of an early cranial decom- 
pression and drainage, and it is in this group of patients having cranial injur- 
ies that the greatest advance in treatment has occurred in recent years and 
a larger percentage of recoveries can still be obtained ; the pathology of the 
condition is now recognized so that the treatment will thus be an earlier 
and more rational one. 

Recent severe brain injuries, with and without a fracture of the skull. 
and associated with high intracranial pressure due, not to large intracranial 
hemorrhage, but to the so-called cerebral edema (an increased amount of 
cerebrospinal fluid). Subtemporal decompression and drainage. Recovery. 

Case 51. — Acute severe brain injury; signs of high intracranial pressure 
due to cerebral edema. Left subtemporal decompression and drainage. 
Excellent recovery. 

No. 025. — Patrick. Thirty-one years. White. Single. Stevedore. Ireland. 

Admitted May 8, 1913, Polyclinic Hospital. Ref erred by Doctor 
A. S. Morrow. 

Operation May 8, 1913 — 18 hours after injury. Left subtemporal 
decompression and drainage. 

Discharged May 16, 1913 — 8 days after operation. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — Sixteen hours ago, while in a bar-room fight, patient was 
repeatedly struck over the head by some heavy, blunt object; was uncon- 
scious for several minutes, and when the police arrived patient was in a 
stuporous, drowsy condition. Taken to the station house and registered as 
"intoxicated"; during the next 12 hours, patient vomited repeatedly and 
bled profusely from the left ear; as bleeding from the left ear lessened, 
patient gradually became more and more stuporous and finally completely 
unconscious ; brought to the hospital in the patrol wagon. 






ACUTE BRAIN INJURIES 275 

Examination upon admission (16 hours after injury). — Temperature, 
99.8°; pulse, 60; respiration, 16; blood-pressure, 142. Semiconscious but 
lapses into total unconsciousness; in the intervals, he can be aroused by 
firm supra-orbital pressure. Multiple lacerations of scalp; over left side 
of head are several very tender areas. Left orbit very ecchymotic. Clotted 
blood in left auditory canal; otoscopic examination reveals a tear of the 
posterior portion of the left tympanic membrane ; left mastoid ecchymosis. 
Pupils — left contracted and does not react to light. Reflexes — patellar very 
active and equal ; no ankle clonus but suggestive right Babinski ; abdominal 
reflexes absent. Fundi — retinal veins dilated; obscuration of entire nasal 
halves and temporal margins of both optic disks — left possibly more than 
right. Lumbar puncture — clear cerebrospinal fluid under high pressure 
(approximately 18 mm.) ; laboratory report (Doctor W. A. MacFarlane) — 
1 ' an occasional red blood-cell in the cerebrospinal fluid. ' ' 

Treatment. — An immediate left subtemporal decompression and drain- 
age advised. 

Operation (18 hours after injury and 2 hours after admission). — Left 
subtemporal decompression: usual vertical incision, bone removed and no 
complications. Dura very tense and upon incising it, clear cerebrospinal 
fluid spurted to a height of almost 3 inches ; upon enlarging the dural opening 
much clear cerebrospinal fluid escaped under pressure, exposing a very 
"wet" edematous cortex which tended to protrude but did not rupture; 
cortex receded and pulsated at the end of the operation. No cortical hemor- 
rhage nor laceration observed — merely a "wet" edematous brain. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes: — Excellent operative recovery ; patient became con- 
scious within 12 hours after the operation and remained clear mentally ; all 
sutures removed upon the fifth day — incision healing per primam. 

Examination at discharge (8 days after operation and 9 days after 
injury; patient was taken to court to answer charges of assault and was 
sentenced to jail for 3 months). — Temperature, 99° ; pulse, 72; respiration, 
18; blood-pressure, 136. No complaints other than "heavy feeling" in the 
head; "light-headed," especially in the morning. Operative wound has 
healed and bulges slightly beyond the flush of scalp ; pulsates normally. 
Hearing of left ear impaired ; bone conduction greater than air conduction. 
Pupils equal and react normally. Reflexes: patellar active but equal: no 
ankle clonus nor Babinski ; abdominal reflexes present and equal. Fundi — 
retinal veins enlarged; nasal margins of both optic disks rather hazy but 
otherwise negative. 

Treatment. — General hygienic measures urged, and especially the avoid- 
ance of alcohol. 

Examination (September 20, 1916 — 40 months after injury). — (Patient 
has been brought to hospital following another fight in which lie has received 
a fractured clavicle.) Except for the general effects of chronic alcoholism, 
patient is in good condition. Decompression area depressed: owing 
to new bone formation, no pulsation is palpable. Hearing of left ear less 
acute ; bone conduction equals air conduction. Reflexes sluggish but other- 



276 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



wise negative. Fundi — general retinal congestion and suffusion but opt 
disks clear and distinct. 

Last Report (June 17, 1918 — 60 months after injury). — Letter from 
patient states that he is in Sing Sing on a third degree charge of homicide 
while intoxicated; sentenced to 5 years' imprisonment. No complaints 
referable to head injury. Hopes by good behavior to obtain an earlier 
release and then ' ' start over again. ' ' 

Remarks. — It is interesting to record the observation made by the police- 
man in charge of this patient in the station house : ' ' The pulse which had 
been around 80 while the ear was bleeding became within 2 hours 66, and 
even 64 after the bleeding from the ear had lessened" (this officer had 
studied medicine before entering the service). The explanation of this 
observation is simple : as long as the intracranial hemorrhage in the cerebro- 
spinal fluid was escaping through the fracture and into the external auditory 
canal, just so much was the intracranial pressure lessened, and thus the 
signs of an increased pressure did not occur ; but when the escape of cerebro- 
spinal fluid was blocked in the ear itself, then this accumulation of excess 
cerebrospinal fluid increased the intracranial pressure until the effect of it 
was to be seen in the fundi, in the measurement of the pressure of the 
cerebrospinal fluid at lumbar puncture and by the signs of mild medullary 
compression as exhibited by the lowering of the pulse- and respiration-rate. 
Undoubtedly in many patients, this escape of blood and cerebrospinal fluid 
through a cranial fracture into the ears or nose is sufficient to prevent a high 
increase of the intracranial pressure and thus a sort of "natural" decom- 
pression is performed and frequently a decompression operation is thus 
avoided, although at the risk of infection and a possible meningitis through 
the fracture into the ear, and particularly into the nose and pharynx. 

The laboratory report of the cerebrospinal fluid indicating the presence 
of a very small amount of blood, might be due either to the intracranial con- 
dition, or, and much more probable in view of the operative findings, 
to the technic of the lumbar puncture itself ; it is very difficult at times not 
to contaminate cerebrospinal fluid by a small amount of free blood due 
to the lumbar puncture itself. 

The gradual improvement of the hearing so that at the examination 40 
months after injury, the bone conduction equalled the air conduction, would 
not indicate that the impairment of hearing of the left ear would eventually 
be normal; those patients in whom the impairment of hearing becomes 
normal, do so within 12 or 18 months following the injury, and the longer 
it takes for the improvement of hearing to occur, the greater is the amount 
of scar tissue and retraction of the tympanic membrane and ossicles so that 
a complete recovery of hearing becomes more and more doubtful. 

The absence of intracranial hemorrhage in this patient does not mean that 
the patient was not seriously injured and in danger of his life, because it is 
not the intracranial hemorrhage that is the serious factor in these cases 
of brain injuries, but rather the degree of increased intracranial pressure ; 
to a certain extent, it is not really a brain injury but the pressure effect, if 
continued, will produce both immediate and remote damage to the cerebral 
cortex, and of greater danger as far as life is concerned, to the medulla itself. 



tic 



ACUTE BRAIN INJURIES 277 

It is a common observation in these patients who have been at all alcoholic, 
that, following a head injury, they are much more liable to an acute cerebral 
edema than are the patients who are not alcoholic ; and also patients accus- 
tomed to the daily use of alcohol are much more liable to be upset, both men- 
tally and emotionally, not only more severely but for a much longer period of 
time. These patients, therefore, should not be allowed to return to their 
former active lives for a period of at least 6 months, and not then unless 
they have returned to their former normal stability ; they should be strongly 
urged not to use alcohol in any form as it renders these patients much more 
liable to future complications, such as epileptiform spells and prolonged 
emotional impairments and states of mental confusion, even to the degree 
of traumatic dementia. These patients also are comparatively bad operative 
risks and this factor of alcoholism must always be considered when it is a 
question of an operation or not. 

In many of these patients, it is better surgical judgment to perform a 
bilateral subtemporal decompression if the intradural pressure is extremely 
high and whenever later it is ascertained that the decompression area 
bulges tensely for a period of at least 10 days ; the fact, however, that the 
cortex pulsates practically normally after the escape of a large amount of 
cerebrospinal fluid at the time of the operation, indicates, as a rule, that a 
bilateral decompression will not be necessary. The rather delayed con- 
valescence with emotional instability may probably have been due to this 
prolonged increase of intracranial pressure associated with the factor of 
alcoholism, and not to a primary injury to the brain itself. 

Case 52. — Acute severe brain injury ; signs of high intracranial pressure 
due to cerebral edema. Right subtemporal decompression and drainage. 
Excellent recovery. 

No. 030. — Vincent. Twenty-eight years. White. Single. Mechanic. 
United States. 

Admitted June 2, 1913, Polyclinic Hospital. Referred by Doctor 
J. A. Bodine. 

Operation June 2, 1913 — 6% hours after injury. Right subtemporal 
decompression and drainage. 

Discharged June 15, 1913 — 13 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While working in a new building, patient fell a distance 
of 2 stories upon a wooden floor; only momentary loss of consciousness and 
was able to walk to the ambulance which brought him to the hospital. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 99.2°; pulse, 64; respiration, 16; blood-pressure, 114. Conscious. 
Patient says he "feels all right," except for a severe headache and a feeling 
of "giddiness," Well-developed and nourished; no alcoholism. Has vom- 
ited twice without nausea. Profuse bleeding and discharge of cerebrospinal 
fluid from right ear; right mastoid ecchymosis. Complete deafness of right 
ear and a slight weakness of right side of face of the peripheral type ^fore- 
head muscles being involved). Pupils equal but react sluggishly. No 
nystagmus. Reflexes — patellar very much increased but equal ; no ankle 



278 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

clonus or Babinski ; abdominal reflexes present and equal. Fundi — retinal 
veins full ; nasal margins of both optic disks blurred and a slight obscuration 
of nasal half of right optic disk visible. Lumbar puncture — clear cerebro- 
spinal fluid under high pressure (approximately 18 mm.). 

Treatment. — Expectant palliative. It was thought advisable to_ observe 
the patient carefully in the hope that he would be able "to take care of" 
the condition itself by natural absorption of the edematous ' ' wet ' ' condition 
of the brain, as indicated by the increased intracranial pressure. However, 
within one hour after this examination, patient became very stuporous, 
drowsy and gradually lapsed into profound unconsciousness 4 hours 
after admission. 

Examination (4 hours after admission). — Temperature, 100° ; pulse, 60; 
respiration, 16 ; blood-pressure, 160. Unconscious. Bleeding and discharge 
of cerebrospinal fluid from the right ear has ceased (about 3 hours ago 
and just before the signs of intracranial pressure became more marked — 
undoubtedly this blockage being a factor in producing the increased intra- 
cranial pressure). Pupils contracted equally and do not react to light. 
Reflexes — patellar very active ; no ankle clonus but suggestive double 
Babinski; abdominal reflexes depressed but equally so. Fundi — retinal 
veins dilated and tortuous ; edematous blurring of both nasal and temporal 
halves of optic disks, but no measurable swelling of the disks themselves. 

Treatment. — An immediate right subtemporal decompression advised in 
order to prevent the more marked signs of medullary compression and pos- 
sibly medullary edema. 

Operation (6 hours after admission). — Right subtemporal decompres- 
sion : usual vertical incision, bone removed and no complications. Dura 
very tense and upon incising it, clear cerebrospinal fluid spurted; upon 
enlarging dural opening, a very "wet" edematous cortex tended to protrude 
under high pressure ; the arachnoid bulged tensely owing to the large amount 
of clear cerebrospinal fluid beneath it and spurted to a height of 3 inches 
when two small openings were made in the arachnoid — these little "foun- 
tains ' ' continuing to spurt to a height of 3 inches for over 2 minutes. Owing 
to the escape of a large amount of this clear cerebrospinal fluid, the tension 
of the cortex lessened and it receded so, that at the end of the operation it 
pulsated almost normally; a bilateral decompression, therefore, was not 
considered necessary ; no hemorrhage nor laceration of the cortex was visible. 
Usual closure with 2 drains of rubber tissue inserted (the lower drain which 
was inserted at the base in the middle fossa of the skull between the temporo- 
sphenoidal lobe and dura was accidentally pulled out at the end of the 
operation ; an attempt was made to re-insert it down to the cortex but 
"blindly").- Duration, 55 minutes. 

Post-operative Notes. — Twelve hours later: Temperature 101.2° ; pulse, 
60 ; respiration, 16 ; blood-pressure, 160. Twenty-four hours later : Tem- 
perature, 101.2°; pulse, 55; respiration, 16; blood-pressure, 160. Thirty 
hours later: Temperature, 101° ; pulse, 50; respiration, 14; blood-pressure, 
170. Besides the gradual lowering of the pulse- and respiration-rates, they 
both became at the last examination rhythmically irregular and of the 
Cheyne-Stokes character; the decompression area was most tense and very 



ACUTE BRAIN INJURIES 279 

little drainage of cerebrospinal fluid appeared. For fear of an increasing 
cerebral edema or possible hemorrhage, it was thought advisable to open the 
decompression wound and this was performed 30 hours after the first opera- 
tion : the cortex was very tense, and ' ' dry, ' ' but no hemorrhage was ascer- 
tained ; the lateral ventricle was tapped, allowing one ounce of blood-tinged 
cerebrospinal fluid to escape but not under pressure. Rubber tissue drain 
inserted properly and wound closed in the usual manner. (Condition con- 
sidered one of temporary edema of a ' ' water-logged ' ' brain. ) As the pulse 
remained between 50 and 56 and at one time descended even to 48, it was then 
debated as to the advisability of a bilateral decompression ; however, as pro- 
fuse drainage of clear cerebrospinal fluid was now occurring, it was decided 
to wait for a period of 24 hours ; by this time the pulse had ascended to 58 
and the general condition of the patient became so much improved that a 
bilateral operation was not considered as being indicated and the patient 
made an excellent recovery. 

Examination at discharge (13 days after admission and operation). — 
Temperature, 98.8° ; pulse, 68 ; respiration, 18 ; blood-pressure, 142. Patient 
complains of an occasional frontal headache and "things sometimes get 
black before my eyes"; general weakness. Patient insisted, however, upon 
going home where he could be "quiet." Only incomplete right facial 
paralysis and there is a definite return of hearing of the right ear — bone 
conduction, however, being greater than air conduction ; otoscopic examina- 
tion discloses a laceration in the inferior portion of right tympanic mem- 
brane. Pupils equal and react normally. Reflexes very active but otherwise 
negative. Fundi — retinal veins enlarged ; nasal margins of both optic disks 
blurred and obscured by edema, but other details of optic disks clear. . Decom- 
pression area bulges beyond flush of scalp and pulsates. Patient advised to 
remain very quietly at home ; daily catharsis and light diet ; no alcohol. 

Examination (June 10, 1914 — 12 months after injury). — Patient com- 
plains of an occasional frontal headache; otherwise well and works daily. 
Decompression area has not "sunken in" possibly as much as it should 
by this time ; normal pulsation, however. No weakness of right side of face 
can be elicited by special tests ; hearing of right ear, however, not as acute 
as left ear ; bone conduction slightly greater than air conduction in right ear. 
Pupils equal and react normally. Reflexes active, but otherwise negative. 
Fundi — retinal veins slightly enlarged; all details of optic disks clear 
and distinct. 

Examination (October 20, 1916 — 40 months after injury). — Patient 
still has an occasional headache but "it doesn't bother me"; works daily at 
former occupation. Decompression area depressed and pulsates normally. 
Reflexes active but otherwise negative. Fundi negative. 

Last Examination (July 16, 1918 — 61 months after injury). — Patient 
says he still has a headache "once in awhile," but "I have become irritable 
and cranky"; upon questioning patient, he admits some financial troubles 
since his marriage last year. Decompression area depressed and slightly 
smaller owing to new bone formation about its periphery ; difficult to palpate 
any pulsation. Impairment of hearing of right ear still present ; bone 



2 8o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

conduction greater than air conduction. Reflexes active but otherwise 
negative. Fundi negative. 

Remarks. — In going over this case, I feel it would have been better sur- 
gical judgment to have performed a bilateral decompression at the time 
of the injury ; the condition was one of severe cerebral edema and the patient 
was very fortunate not to have been permanently damaged — it was too 
great a risk not to have performed a bilateral decompression at the time. 
It will be very interesting to follow this patient for a longer period, as it is 
difficult to conceive of his not being rendered emotionally unstable at least. 

It is possible that the lower drain was not reinserted properly so that lit- 
tle or no drainage could occur ; otherwise, if excellent drainage had occurred 
it is very probable that this secondary increase of intracranial pressure 
following the operation would not have happened. This lower drain in- 
serted into the middle fossa between the inferior surface of the temporo- 
sphenoidal lobe and the underlying dura affords excellent drainage of hemor- 
rhage or cerebrospinal fluid collected in the middle fossa — a large cistern 
at the base of the skull; it is very important in these patients that this drain 
be placed accurately in order to insure efficient drainage. 

It was a very significant observation that the signs of an increasing intra- 
cranial pressure occurred rapidly following the cessation of the discharge of 
blood and cerebrospinal fluid from the right ear; to a large extent, this 
patient was ' ' decompressing ' ' himself by means of this channel of escape, but 
it is doubtful whether this amount of drainage would have been of sufficient 
quantity to have lessened the high increased intracranial pressure of this 
patient to such an extent that the operation of subtemporal decompression 
and drainage could have been avoided. This escape of blood and cerebro- 
spinal fluid through a line of fracture into the ear rarely persists longer 
than 48-60 hours, and if it should, then the danger of infection of the ear 
and a possible meningitis becomes greater daily ; repeated lumbar punctures 
may be advisable in these patients if the increased intracranial pressure 
is not extreme and in this way the discharge from the ear can be stopped. 

The impairment of hearing is undoubtedly a permanent one due to the 
formation of scar tissue in the tympanic membrane and about the ossicles 
together with their retraction, and thus the bone conduction will always 
be greater than the air conduction ; fortunately, in these traumatic cases the 
impairment of hearing is usually only a temporary one, unless the internal 
ear and the auditory nerve itself has been damaged. 

The temporary facial paralysis of the peripheral type was undoubtedly 
due to a mild edematous compression of the facial nerve at the usual site — 
its narrow bony canal, the aqueduct of Fallopius. Unless the facial nerve 
itself is severed or firmly compressed by bone, then the facial paralysis of 
these patients is of only temporary duration. 

Case 53. — Acute severe brain injurj^ ; signs of high intracranial pressure 
due to cerebral edema. Right subtemporal decompression and drainage. 
Excellent recovery. 

No. 651. — Fabian. Twenty-three years. White. Single. Laborer, 
Poland. 

Admitted January 6, 1916, Polyclinic Hospital. 



ACUTE BRAIN INJURIES 2 8r 

Operation January 12, 1916 — 6 days after injury. Right subtemporal 
decompression and drainage. 

Discharged March 1, 1916 — 48 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While riding a horse to work, patient was thrown,, 
striking his head against a rock ; immediate loss of consciousness ; brought 
to the hospital in ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 97.8°; pulse, 132; respiration, 38; blood-pressure, 104. Unconscious 
and in extreme shock. Laceration of scalp over right eye. No bleeding- 
from nose, mouth or ears. Superficial examination reveals the reflexes absent 
while the pupils are dilated and non-reacting to light. 

Treatment. — Vigorous anti-shock measures instituted: external warmth 
being most important — the blankets of the bed having been thoroughly 
warmed and at least 6 hot-water bottles applied to body (to both feet, between 
the thighs, in the axillae, etc.) ; hot black coffee enemata; quiet. Patient 
gradually emerged from the condition of shock after 4 days and 2 days later, 
after being in a semiconscious condition, patient began to show the signs of 
an increasing intracranial pressure. 

Examination (6 days after admission). — Temperature, 101.2°; pulse, 
64; respiration, 16; blood-pressure, 140. Patient has become increasingly 
difficult to arouse, although his general condition is fair; takes liquid by 
mouth ; bowels move daily. Otoscopic examination negative. Pupils 
equal and react normally. Reflexes — patellar very much exaggerated but 
equal ; double exhaustible ankle clonus and suggestive Babinski ; abdominal 
reflexes depressed. Fundi — retinal veins have become dilated and the 
nasal halves of both optic disks have become entirely obscured, as well as the 
temporal margins which before had been clear and distinct. Lumbar punc- 
ture — slightly blood-tinged cerebrospinal fluid under high pressure (approxi- 
mately 18 mm.). X-ray (Doctor A. J. Quimby) — ''multiple lines of frac- 
ture of right squamous area of vault" (Fig. 77). 

Treatment. — An immediate right subtemporal decompression and drain- 
age was now advised in the belief that to delay longer would risk not only 
the life of the patient but also his future good health. 

Operation (6 days after admission). — Right subtemporal decompression : 
usual vertical incision, bone removed and no complications ; irregular line of 
fracture of squamous portion of right temporal bone bifurcating anteriorly 
into right frontal and superiorly into right parietal bones. Dura moder- 
ately tense and upon incising it, clear cerebrospinal fluid welled out under 
moderate pressure; upon enlarging dural opening, a moderately ''wet" 
edematous cortex tended to protrude but did not rupture and it very 
quickly receded owing to the loss of cerebrospinal fluid. No subdural 
hemorrhage nor cortical laceration ascertained. Usual closure with 2 drains 
of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery, 
but he remained in a mild state of mental confusion and disorientation for 
a period of several weeks, so much so that it was finally decided to transfer 



282 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



the patient to Bellevue Hospital, where he could remain for a period of 
months until he might regain his normal condition; incision healed 
per primam. 

Examination at discharge (54 days after admission and 48 days after 
operation). — Temperature, 99°; pulse, 78; respiration, 22; blood-pressure, 
136. No complaints — ' ' I feel all right. ' ' Patient, however, has a definite 
mental confusion and also retardation with a moderate degree of cortical 
irritability, as disclosed in his restlessness, inability to sleep and emotional 
instability. Decompression area slightly depressed; pulsates normally. 
Pupils equal and react normally. Reflexes very active but otherwise nega- 
tive. Fundi — retinal veins slightly enlarged but no edema of optic disks. 
Last Report (Augunst 20, 1918 — 19 months after injury). — Patient is 

in the army and has been in 
good health during the past 
year. It was, however, 9 
months after the injury be- 
fore the patient "became 
himself again." (A further 
report regarding this patient 
will be made if he can be 
located later.) 

Remarks. — The advisabil- 
ity of waiting until the signs 
of severe shock had disap- 
peared is very evident in this 
case; if an operation had 
been performed during the 
period of severe shock — no 
matter how badly the brain 
had been injured, the risk of 
such an operation at that 
time would have been very 
great indeed ; besides, during 
the period of severe shock 
there were no signs of a marked increase of the intracranial pressure and 
therefore no indication for the operation of decompression — a marked in- 
crease of the intracranial pressure being the only indication for advising a 
cranial decompression upon these patients; naturally all cases of depressed 
fractures of the vault are not included in this grouping as they should all be 
operated upon — the depressed area being elevated or removed. I feel, 
however, in this particular case, that the operation of decompression should 
have been advised earlier — at least 24 hours — and possibly 48 hours before, 
and it is possible that the post-operative mental and emotional disturbances 
could have been lessened, if not entirely avoided. 

It is rather surprising that there was no impairment of the right middle 
ear in this patient due to a possible line of fracture extending into the right 
petrous bone. The rontgenogram indicated several lines of fracture extend- 
ing through the right squamous bone and beyond which was confirmed at 




Fig. 77. — Two oblique and parallel linear fractures of the 
posterior portion of the right squamous bone in a patient hav- 
ing a high intracranial pressure due to cerebral edema alone; 
right subtemporal decompression and drainage permitted an 
excellent recovery. 



ACUTE BRAIN INJURIES 283 

the operation; usually in these patients having fractures of the squamous 
portion of the temporal bene, the line of fracture extends downward into 
the middle fossa and into the petrous bone adjacent to the middle ear and 
thus frequently causing a rupture of the tympanic membrane and the dis- 
charge of blood and cerebrospinal fluid into the middle ear. In this patient, 
however, neither was there blood blocked in the middle ear, as the otoscopic 
examination was negative, nor was the tympanic membrane lacerated. It 
would seem, therefore, that the tympanic cavity had escaped the line of 
fracture in this case, if the fracture did descend into the middle fossa of 
the skull ; the fact that there was no right mastoid ecchymosis would con- 
firm this opinion in addition to the fact that the hearing was not impaired. 

It is very instructive to follow a patient of this character who has regained 
completely his normality as before the injury ; no doubt, a certain percentage 
of these patients would have recovered their lives and also have regained 
even their normal condition as before the injury without any operation hav- 
ing been performed upon them ■ but it is indeed much safer to perform the 
operation of subtemporal decompression under the proper conditions of 
assistance and asepsis upon these patients early and thus avoid not only the 
danger of medullary compression and possibly edema, and thus the death 
of the patient, but also in a larger number of them to avoid those post- 
traumatic conditions so common in patients following brain injuries, where 
the increased intracranial pressure has not been relieved by an earlier cranial 
operation. Besides, it is impossible to ascertain just which patients will 
recover not only their former normality but even their lives at the time of 
the injury, and therefore in cases of doubt, I feel it is wiser to advise the 
operation as a certain means of lessening the intracranial pressure rather 
than to depend upon the means of natural absorption to lessen the increased 
intracranial pressure, and then if it should not, it is frequently too late 
not only to obtain a normal individual but also to cause even a recovery 
of life itself. A study of the statistics regarding these data in this series of 
patients confirms this opinion. 

It will be observed that a number of patients in this series of acute 
brain injuries with early operation that X-ray pictures were taken in only 
a small number of them ; this is due to the fact that most of these patients 
were in a very critical condition after their admission to the hospital and 
as the X-ray picture is of no importance in their treatment (except when 
it is a question of a depressed fracture of the vault), rontgenograms were 
taken in only a few of the patients ; also, as most of these patients were dis- 
charging blood and cerebrospinal fluid from either or both ears, a fracture 
of the skull was known to be present, but as is well known the important 
factor to be ascertained is not the presence or not of a fracture of the skull, 
whether of the vault or of the base, but the presence or not of a marked 
increase of the intracranial pressure, which can be accurately ascertained 
by the careful tests as described in these patients. It is to be regretted, 
however, that rontgenograms were not made of all of the skulls of those 
patients during their convalescence at least and as a matter of record 
alone; this should be done in all cases of brain injuries and possible 
fractures of the skull. 



284 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 54. — Acute severe brain injury ; signs of high intracranial pressure 
due to cerebral edema. Left subtemporal decompression and drainage. 
Excellent recovery. 

No. 679. — Thomas. Twenty-six years. White. Single. Clerk. Poland. 

Admitted March 25, 1916, Nassau Hospital, Mineola. Referred by 
Doctor L. A. Van Kleeck. 

Operation March 28, 1916 — 72 hours after injury. Left subtemporal 
decompression and drainage. 

Discharged April 20, 1916 — 22 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While coasting down a hill, patient was struck by an 
automobile; immediate loss of consciousness; brought to the Nassau Hos- 
pital in the automobile, and upon arrival patient was in a moderate degree 
of shock — temperature, 98° ; pulse, 108 ; respiration, 28 ; blood-pressure, 116. 
Semiconscious but could be aroused by firm supraorbital pressure. No bleed- 
ing from nose, mouth or ears. Pupils enlarged but equal and react sluggishly 
to light. Reflexes active but otherwise negative. Patient gradually recov- 
ered from the condition of shock; the pulse descended to 70, the blood- 
pressure increased to 130 and patient became more conscious, but could not 
speak at any time. As the signs of intracranial pressure were increasing, 
a consultation was now considered advisable. 

Examination (March 28, 1916 — 70 hours after injury). — Consultation 
with Doctor Van Kleeck: Temperature, 99.8°; pulse, 60; respiration, 18; 
blood-pressure, 142. Conscious but drowsy — could be aroused but would 
quickly lapse into unconsciousness. Unable to speak a word when conscious — 
a condition of pure motor aphasia ; no agraphia ; no astereognosis. Definite 
weakness of right side of body, particularly of lower right side of face (cor- 
tical type of facial paralysis in that the forehead muscles were not involved) . 
Pupils equal and react normally. Reflexes — patellar exaggerated, right 
being possibly greater than left; suggestive right Babinski; abdominal 
reflexes — right depressed. Fundi — retinal veins dilated and tortuous; both 
nasal halves and temporal halves of optic disks obscured but no measurable 
swelling — that is, not a * ' choked disk, ' ' but a papilledema of early degree. 
Lumbar puncture — clear cerebrospinal fluid under high pressure (approxi- 
mately 18 mm.). 

Treatment. — An immediate left subtemporal decompression advised to 
lessen the increasing intracranial pressure; there was no bleeding or dis- 
charge of cerebrospinal fluid through the nose or ears, which is usually very 
helpful in lessening a moderate increase of the intracranial pressure, while 
the risk of infection and a resulting meningitis are comparatively of 
rare occurrence with proper prophylactic measures. Before preparing 
the patient for operation, the accompanying photographs were taken 
(Figs. 78-81). 

Operation (72 hours after admission). — Left subtemporal decompres- 
sion : usual vertical incision, bone removed and no complications. Dura very 
tense and upon incising it, a slightly straw-colored cerebrospinal fluid 
spurted a distance of 3 inches; upon enlarging dural opening, a very 



ACUTE BRAIN INJURIES 



28; 



congested cortex was exposed, being very ' ' wet ' ' and edematous, particularly 
beneath the Sylvian fissure ; large quantities of cerebrospinal fluid escaped 
and thus permitted the brain to recede so that the cortical protrusion did 



Fig. 78. 



Fig. 79. 




Fig. 80 



Figs. 78-81. — Right facial paralysis of the cortical central type due to an extensive cerebral edema 
of the left cortical hemisphere; an excellent recovery obtained by means of a left subtemporal decompression 
and drainage. Note the ability of the patient to corrugate the muscles of the right half of the forehead. 
and to close the right eye — thereby differentiating this central type of paralysis from the peripheral type, 
due to a lesion of the facial nerve itself. The deviation of the tongue to the right is well illustrated. 



not rupture and normal pulsation occurred before the end of the operation. 
No punctate cortical hemorrhage nor lacerations were visible — merely a 
slightly blood-tinged subarachnoid cerebrospinal fluid which continued to 
" sweat" throughout the operation. Usual closure with 2 drains of rubber 
tissue inserted. Duration, 50 minutes. 

Post-operative Notes. — Uneventful operative recovery: within 24 hours 
after operation, patient became more conscious than at any time since the 



286 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

injury, the pulse ascended to 76 and the weakness of the right side of the 
face practically disappeared. Patient began to use monosyllables on the 
fourth day after operation and then his speeceh rapidly improved. 

Examination at discharge (25 days after admission and 22 days after 
operation). — Temperature, 98.6° ; pulse, 78; respiration, 20. Perfectly con- 
scious. No complaints except for a dull headache. Some slight impairment 
of speech elicited by the test phrases (patient being Polish and not speaking 
English well, an accurate estimate of his speech impairment was very diffi- 
cult). No weakness of right side of body ascertained. Pupils equal and 
react normally. Reflexes active but otherwise negative. Fundi negative, 
except for a slight enlargement of the retinal veins. Decompression area does 
not bulge beyond the flush of scalp ; normal pulsation. 

Last Report (August 17, 1918 — 29 months after injury). — No com- 
plaints; patient works daily. No impairment of speech and no weakness 
of the right side of body apparent to patient. In excellent condition both 
mentally and physically. 

Remarks. — It is interesting to note that there was no large hemorrhage 
present over the cortex of the motor speech area or the face area involved — 
there being only a very ' ' wet ' ' edematous cortex with congested supracortical 
vessels. This would tend to confirm the belief that a localized cortical edema 
was the cause of the speech impairment and of the weakness of the right side 
of the face, so that, as soon as a decompression was performed and proper 
drainage instituted for this "pent up" cerebrospinal fluid, the condition 
quickly disappeared and an excellent recovery was obtained — there being 
no definite organic lesion which would produce a permanent impairment. 
If there had been a fracture through the left petrous bone so that the cerebro- 
spinal fluid could have escaped through this line of fracture and through 
a torn tympanic membrane out into the external auditory canal, then this 
patient would have had an excellent chance of "decompressing" himself 
and thus the risk of an operation would have been avoided. 

The condition of pure motor aphasia is a most infrequent one and yet this 
patient at the examination before operation appeared to have it, in that 
when conscious, he was able to understand both spoken and written 
words, and could write words and answers in his own language (Polish), 
but he was unable to speak either spontaneously or by repeating words 
either in English or Polish ; there was no apraxia. That is, in the case of 
a box of matches he was able to write "matches," upon being asked what 
they were ; he was able to pick up a match from a number of objects when 
requested to do so, and upon being asked what they were used for, he went 
through the motion of striking a match, and then wrote, ' ' to light the fire ' ' ; 
with his eyes closed, patient was able to write down afterward the names of 
various objects which had been placed in his hand, therefore, there was no 
astereognosis present. From the other examinations also, it would seem that 
this patient had an uncomplicated condition of motor aphasia, so that at the 
operation of left subtemporal decompression (his parents and grandparents 
all being right-handed), a definite lesion and most probably a hemorrhage 
was anticipated in the cortex of the posterior portion of the third left frontal 
convolution — Broca 's motor speech area ; only an extreme edematous con- 



ACUTE BRAIN INJURIES 287 

dition of this area of the cortex was observed — an acute cerebral edema — 
and this observation was confirmed by the rapid subsidence and disappear- 
ance of the motor aphasia following the operation of decompression 
and drainage. 

The right facial paralysis of the cortical type in that the right forehea^ 
muscles were not involved was undoubtedly due to the same cause — an 
acute cortical edema following the injury; the almost immediate recovery 
from this facial weakness after the operation of decompression and drainage 
would also confirm the diagnosis of acute cortical edema — at least of the left 
cerebral cortex. The immediate disappearance of the left hemiplegia fol- 
lowing operation, when only a "wet" edematous cortex was revealed at 
operation, would tend to confirm the opinion that localized cerebral edema — 
or rather cerebral edema more acute in one portion of the brain than 
in another — is- a definite factor and possibly the only factor in some 
patients in producing a definite paralysis; repeated lumbar punctures to 
improve the condition of this patient would have been very interesting 
and instructive. 

Case 55. — Acute severe brain injury ; signs of high intracranial pressure 
due to cerebral edema. Left subtemporal decompression and drainage. 
Excellent recovery. 

No. 564. — Florence. Fourteen years. White. School. U. S. 

Admitted May 2, 1916, Polyclinic Hospital. 

Operation May 3, 1916 — 90 hours after injury. Left subtemporal 
decompression and drainage. 

Discharged May 17, 1916 — 14 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Three days ago while patient was playing in the street,. 
a brick fell a distance of 4 stories, striking her upon the head ; immediate loss 
of consciousness and she did not become semiconscious until 2 hours later ; 
very dizzy but still able to walk home ; since then, patient has had severe con- 
tinuous headache and dizziness ; brought to the hospital in an automobile. 

Examination upon admission (70 hours after injury). — Temperature, 
99.6°; pulse, 70; respiration, 20; blood-pressure, 124. Well-developed and 
nourished. Conscious, but rather drowsy and complains of severe frontal 
and occipital headache ; keeps her eyes closed and feels less dizzy by doing so. 
No bleeding from nose, mouth or ears. A large hematoma — the size of an 
egg, over the posterior portion of the left parietal bone. Pupils equal and 
react normally. Reflexes very active but otherwise negative. Fundi : retinal 
veins engorged and tortuous in places obscured by edema ; papilledema of 
2 diopters — both optic disks being entirely obscured by the edema — that is. 
almost to the degree of "choked disks." Lumbar puncture — clear cerebro- 
spinal fluid under high pressure (approximately 20 mm.). X-ray (Doctor 
W. H. Stewart) — "shows a sagittal fracture extending posteriorly downward 
into the occipital bone ; then forward on the right side into the posterior 
fossa, running anteriorly into the base back of the mastoid cells.'* 

Treatment. — An immediate left subtemporal decompression advised to 
lessen the intracranial pressure in the belief that a medullary compression 



288 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

might be avoided; the ophthalmoscopic examination revealing practically 
a "choked disk" in each fundus was very impressive and removed this 
patient immediately from that large group of patients in whom the expect- 
ant palliative treatment is sufficient. Consent for the operation was not 
obtained until following day. 

Operation (90 hours after injury). — Left subtemporal decompression; 
exploratory scalp incision of hematoma. Usual incision, bone removal and 
no complications. Dura exceedingly tense ; upon incising it, slightly straw- 
colored cerebrospinal fluid spurted to a height of 1 foot, striking the operator 
in the eye; upon enlarging the dural opening, a very "wet" edematous 
cortex tended to protrude, but owing to the rapid loss of much cerebrospinal 
fluid (slightly straw-colored), the cortex did not rupture and its tension 
soon lessened so that it was pulsating at the end of the operation. No cor- 
tical hemorrhage or laceration ascertained. Usual closure with 2 rubber 
tissue drains inserted. Small vertical scalp incision now made over the 
hematoma ; a small subcutaneous blood-clot evacuated, but upon retraction 
no fracture of the underlying bone revealed; incision loosely sutured with 
one drain of rubber tissue inserted. Duration, 60 minutes. 

Post -operative Notes. — Uneventful operative recovery: patient was con 
scious and rational within 24 hours and did not complain of headache except 
for soreness at the site of operation ; pulse ascended to 86, and at the end of 
48 hours the nasal halves only of both optic disks were blurred. Both 
incisions healed per primam. 

Examination at discharge (18 days after injury and 14 days after 
operation). — Temperature, 98.8° ; pulse, 82; respiration, 24; blood-pressure, 
126. No complaints. Decompression area bulges slightly beyond the flush of 
scalp ; normal pulsation. Hearing negative ; otoscopic examination negative. 
Pupils equal and react normally. Reflexes active but otherwise negative. 
Fundi — retinal veins enlarged ; upper nasal sector of margins of both optic 
disks blurred and indistinct from edema. 

Examination (September 20, 1917 — 16 months after injury). — No com- 
plaints ; patient was able to return to school 4 months after the injury and 
has been perfectly well. Decompression area slightly depressed and pulsates 
normally. Reflexes active but otherwise negative. Fundi negative. 

Last Examination (August 22, 1918 — 27 months after injury). — No 
complaints; patient has been working this summer as a salesgirl. Decom- 
pression area depressed and pulsates normally. Reflexes negative. 
Fundi negative. 

Remarks. — It is rare for a patient with an acute brain injury to have 
a papilledema to the extent of ' ' choked disks ' ' and yet with so few signs of 
an increased intracranial pressure as this patient ; the headache was severe 
but there were practically no signs of a medullary compression which might 
oe expected in an acute intracranial condition having so high an increased 
pressure as to produce a papilledema of 2 diopters and to register approxi- 
mately 20 mm. of pressure at lumbar puncture. It seems to be, however, 
merely another illustration of the facility with which high intracranial 
pressure in children is withstood, and conversely the great difficulty for 
increased intracranial pressure to produce the signs of medullary compres- 



ACUTE BRAIN INJURIES 289 

sion, however mild, in children around the age of 12 years and younger; 
not only can these patients withstand safely a higher intracranial pressure 
than can adults but their powers of natural absorptioon, are much greater, 
and therefore the treatment of these patients from an operative standpoint 
can be much more conservative than that of adults where the danger of high 
intracranial pressure in acute conditions is most grave. 

The presence of a small amount of blood in the cerebrospinal fluid in this 
patient was of such little quantity that it could not in itself have produced, 
I believe, any untoward symptoms or signs, so that the intracranial pressure 
was due almost entirely to an excess of the cerebrospinal fluid producing 
this so-called "cerebral edema." 

The hematoma over the posterior portion of the left parietal bone was 
incised in order to ascertain the presence or not of an underlying fracture 
of the bone ; if depressed, then it could be elevated or removed, and if merely 
a linear fracture was present then the hematoma could be evacuated and 
drained, and thus the danger of an infection of the hematoma extending 
downward through the line of fracture and producing a meningitis and its 
complications of brain abscess, etc., could be thus avoided. No fracture of 
the underlying bone being ascertained, however, the hematoma itself was 
merely evacuated, drained and healing per primam resulted. The skin 
overlying the hematoma was rather bruised and contused, and these are 
just the cases where an underlying hematoma becomes infected very easily, 
and if there is present an underlying fracture of the skull and the infected 
hematoma is not drained early, most serious consequences intracranially may 
occur. If it is definitely known that there is no underlying fracture of the 
vault, then in certain selected patients the hematoma may be aspirated 
through a ' ' clean ' ' area and thus the danger of an infection of the hematoma 
is also lessened. I have had several patients die from an infection of a sim- 
ple hematoma of the scalp with and, in one case, without a fracture of 
the underlying vault, and this disastrous result is most impressive. 

The rontgenograms of this patient show a fracture of the skull in a most 
dangerous part of the skull — extending subtentorially and near the foramen 
magnum and across the lateral sinus. The danger of an acute medullary 
compression with its resulting medullary edema is very great in this type 
of cranial injury, and especially in adults ; children are not so susceptible to 
an acute medullary compression and therefore the prognosis, with and with- 
out operation, upon children is usually much better than in the older patients. 

Case 56. — Acute severe brain injury ; marked signs of high intracranial 
pressure due to cerebral edema. Eight subtemporal decompression and 
drainage. Recovery. 

No. 587. — David. Twenty-six years. White. Single. Taxi-driver. U.S. 

Admitted May 24, 1916, Polyclinic Hospital. 

Operation June 12, 1916 — 18 days after injury. Right subtemporal 
decompression and drainage. 

Discharged June 24, 1916 — 12 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While driving his taxicab, patient was struck by an 
19 



2 9 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

automobile; immediate loss of consciousness; brought to the hospital in 
the automobile. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 92 ; respiration, 18 ; blood-pressure, 138. Unconscious, 
but can be aroused by firm supraorbital pressure. Large hematoma over the 
right occipital area. No bleeding from nose, mouth or ears; no orbital 
nor mastoid ecchymoses. Pupils slightly enlarged but react normally. 
Reflexes present and equal; no Babinski. Fundi negative. Lumbar punc- 
ture — clear cerebrospinal fluid under very slightly increased intracranial 
pressure (approximately 10 mm.). 

Treatment. — Expectant palliative ; only a mild degree of shock is present 
and at this time, the patient was considered as having the condition of cere- 
bral concussion and the prognosis was good. Within 20 hours patient became 
sufficiently conscious to be able to talk rationally ; he remained, however, in a 
very apathetic, drowsy condition — sleeping most of the time and without 
marked signs of high intracranial pressure for a period of 2 weeks ; no abnor- 
mality of the reflexes noted. Fundi showed signs of mild intracranial pres- 
sure, although at 2 different lumbar punctures the cerebrospinal fluid was not 
under high intracranial pressure; the pulse, however, had descended to 60 
and had remained thereabouts during the 2 weeks. Patient did not show a 
marked improvement during this period and remained in a drowsy lethargic 
condition — neither improving nor becoming markedly worse until June 11, 
1916 (17 days after admission) , when the patient became definitely worse and 
the signs of a marked increase of intracranial pressure appeared. 

Examination (17 days after admission) . — Temperature, 99.2° ; pulse, 58 ; 
respiration, 16 ; blood-pressure, 140. Very stuporous but can be aroused 
by firm supraorbital pressure. Pupils equal but react rather sluggishly. 
Reflexes — patellar present and equal ; no Babinski nor ankle clonus ; abdom- 
inal reflexes equal but rather depressed. Fundi (Doctor J. A. Kearney) — 
"retinal veins very much enlarged; both optic disks completely obscured 
by edema — the elevation of tissue being 2 diopters plus ; fundi about disks 
hemorrhagic and vessels buried in the new tissue formation." Lumbar 
puncture — clear cerebrospinal fluid under high intracranial pressure (ap- 
proximately 22 mm.) ; Wassermann test negative. 

Treatment. — An immediate right subtemporal decompression now ad- 
vised to lessen this sudden increase of the intracranial pressure ; consent, 
however, for the operation was not obtained until 20 hours later. 

Operation (18 days after injury and admission). — Right subtemporal 
decompression : usual vertical incision, bone removed and no complications. 
Dura thickened, tense and very vascular ; upon incising it, clear cerebro- 
spinal fluid welled out, and upon enlarging the dural opening a very "wet" 
edematous cortex protruded, but did not rupture owing to the rapid escape 
of a large quantity of cerebrospinal fluid. Cortex showed throughout many 
old punctate hemorrhages — being very similar to the cross section of spleen ; 
about the vessels in the sulci there was a subarachnoid thickening and whitish 
induration as though due to the organization of a former subarachnoid 
hemorrhage. The cortical tension was so high at the very beginning of the 
operation that the lower margin of the third temporal convolution ruptured 



ACUTE BRAIN INJURIES 291 

for a distance of one-half inch. Brain pulsated normally at end of operation. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 55 minutes. 

Post-operative Notes. — Within 24 hours after operation, patient became 
more conscious and rational than at any time following the injury ; the pulse, 
however, remained , between 60 and 66 for a period of 5 days and then 
ascended to 70 ; decompression area bulged very tensely for 5 days, and as 
it lessened its protrusion, the fundi cleared so that the temporal margins 
of both optic disks became visible. 

Examination at discharge (30 days after admission and 12 days after 
operation). — Temperature, 99°; pulse, 70; respiration, 18; blood-pressure, 
134. Rational and yet a definite mental retardation — both in thinking and 
talking. No complaints, except "I want to sleep all the time." Decom- 
pression wound bulges slightly beyond the flush of scalp ; pulsation normal. 
Pupils equal and react normally. Reflexes present and equal and no abnor- 
mality. Fundi (Doctor J. A. Kearney) — "nasal margins of both optic disks 
not clear ; surrounding retinae rather congested and suffused ; retinal vessels 
possibly a little enlarged." 

Treatment. — Patient insisted upon going home ; his relatives were advised 
to keep him at home and as quietly as possible. 

Examination (April 20, 1917 — 11 months after injury). — Patient has 
made an unexpected and unusually good recovery. No complaints and works 
daily, driving a hansom-cab; is becoming, however, more and more alcoholic 
with marked tremor of both hands. Apparent retardation of speech, 
although his mother states the patient was always a little ' ' slow ' ' and not so 
"quick" as her other sons. Pupils equal and react normally. Reflexes 
present and equal. Fundi rather congested and suffused throughout entire 
retinas, but no obscuration of details of optic disks. Decompression area 
slightly depressed and pulsates normally. 

Last Examination (August 4, 1918 — 26 months after injury). — No com- 
plaints referable to head injury ; patient, however, is in his usual condition 
of mild intoxication, but always able to perform his work as a driver 
without accident. Decompression area only slightly depressed and pul- 
sates normally. Reflexes negative. Fundi still rather congested and suf- 
fused, but no blurring of the details of optic disks. Urine examination — 
small trace of albumen with an occasional Iryaline and granular cast. 

Remarks. — The condition of this patient was a most puzzling one in that, 
at operation almost 3 weeks after the injury, the signs of definite subarach- 
noid and even cortical punctate hemorrhages were found, and yet it was 
not until 17 days after the injury that the signs of a high increase of intra- 
cranial pressure appeared; undoubtedly, it was a case of delayed cerebral 
edema superimposed upon the condition of subarachnoid, and cortical 
punctate hemorrhages — the latter in themselves not being of sufficiently 
large amount to produce signs of a marked increase of the intracranial 
pressure. Undoubtedly there are many similar latent cerebral conditions 
with hemorrhage following head injuries which are not recognized but 
are considered to be merely conditions of cerebral edema, and then when 
the patient does not make such a good recovery as would be expect e J 
from a condition of simple cerebral concussion, then the condition is con- 



2 9 2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

sidered one of post-traumatic neurosis and so labelled. If this patient had 
been in better physical condition at the time of the injury (particularly in 
regard to alcoholism and his general resistance), he might have been able 
himself to have "taken care of" the intracranial condition by means of 
simple absorption, and thus have prevented the onset of an acute cerebral 
edema which was the immediate cause of the high intracranial pressure and 
thus rendering a decompression imperative to avoid a marked medullary 
compression and possibly medullary edema. In patients having similar 
conditions, naturally no operation can be advised unless there are definite 
signs of an increased intracranial pressure; it might be argued that a 
decompression with drainage would aid in the natural absorption of the 
subarachnoid hemorrhage and possibly the cortical punctate hemorrhages, 
and yet this condition cannot be with certainty diagnosed, and if there is 
no increased pressure naturally a decompression cannot be advised ; I believe 
that the great majority of these patients having similar conditions make 
excellent recoveries without any operation; if, however, the signs of an 
increased intracranial pressure do occur, then the operation of decompression 
and drainage should be immediately advised. This condition of latent cere- 
bral edema following brain injuries occurs most frequently in alcoholics, 
and it is the cause of the high mortality of brain injuries in this type of 
patient — the acute cerebral edema occurring earlier in most of the patients 
than in this case. This patient is also interesting in that the cerebrospinal 
fluid removed by lumbar puncture was clear each time, and yet there was 
present intracranially subarachnoid bleeding ; this observation tends to con- 
firm the experimental work of Doctor Norman Sharpe regarding the direction 
of the flow of the cerebrospinal fluid which flows up from the fourth ven- 
tricle over the cortex first rather than from the ventricle down into the spinal 
canal ; if, however, the supracortical hemorrhage is of large amount then the 
blood appears in the spinal cerebrospinal fluid without difficulty. 

Case 57. — Acute severe brain injury; marked signs of extreme intra- 
cranial pressure due to a high and increasing cerebral edema. Bilateral 
decompression and drainage. Excellent recovery. 

No. 166. — Walter. Thirty-two years. White. Married. Reporter. U. S. 

Admitted May 6, 1914, Polyclinic Hospital. Referred by Doctor 
J. A. Bodine. 

Operations May 9, 1914 — 3 days after injury. Bilateral decompression 
and drainage. 

Discharged May 19, 1914 — 10 days after operations. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was struck by an 
automobile; immediate loss of consciousness; brought to the hospital in 
the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 97.4° ; pulse, 144; respiration, 6 (?) ; blood-pressure, 104. Well-devel- 
oped and nourished. Unconscious and in condition of extreme shock — cold, 
clammy skin, irregular weak pulse and respiration scarcely perceptible. No 
bleeding from nose, mouth or ears. No examination other than this was 



ACUTE BRAIN INJURIES 



293 



made on account of the severity of the shock, although it was noted that 
the pupils were widely dilated and did not react; patient was consid- 
ered moribund. 

Treatment. — Vigorous anti-shock measures instituted: patient imme- 
diately placed in a warm bed (blankets having been themselves warmed) , hot- 
water bottles distributed as follows — 2 bottles for feet, one for each side of 
chest under arm-pit, one upon abdomen with palms of both hands resting 
upon it and one between the thighs ; 6 ounces of hot black coffee per rectum 
and repeated every 2 hours for 4 times and then hot rectal saline every 4 hours 
substituted ; absolute quiet. After 6 hours, patient improved in his general 
condition and the shock became less marked — pulse descended and became 
more regular and full, respiration became more perceptible and regular; 
patient became semiconscious and restless. 

Examination (72 hours after admission). — Temperature, 100°; pulse, 
56 ; respiration, 18 ; blood- 
pressure, 146. Pat i e n t 
conscious but confused men- 
tally ; the pulse has gradually 
descended to 56. No bleed- 
ing from the ears ; no mastoid 
ecchymoses. Pupils — 1 eft 
larger than right and reacts 
sluggishly to light. Reflexes : 
patellar — right greater than 
left; no ankle clonus but 
right Babinski ; abdominal 
reflexes — right depressed but 
still can be elicited. Fundi 
— retinal veins dilated, tor- 
tuous and buried in the ede- 
matous retinas, especially 
about the disks; both optic 
disks entirely obscured by 
edema and there is a papill- 
edema of 2 diopters — that is, an edematous swelling of the optic disks 
equalling the first stage of "choked disks." Lumbar puncture — bloody 
cerebrospinal fluid under high intracranial pressure (22 mm.). X-ray 
(Doctor A. J. Quimby) — "definite oblique line of fracture extending down- 
ward from right parietal bone into right squamous bone" (Fig. 82). 

Treatment. — An immediate left subtemporal decompression advised in 
the hope that it might prevent the onset of severe medullary compression. 

First Operation (May 9, 1914 — 74 hours after admission). — Left subtem- 
poral decompression : usual vertical incision, bone removed and no compli- 
cations. Dura exceedingly tense and bulging ; upon incising it, clear cerebro- 
spinal fluid spurted to a height of 1 foot and upon enlarging the dural open- 
ing, the bulging temporo-sphenoidal lobe tended to protrude and portions of 
it did "ooze out" — especially from its lower half; upper portion of temporal 
lobe was also lacerated by this herniation ; no free subdural blood observed 




Fig. 82. — Indefinite linear fracture of the right vault extending 
into the squamous portion of the right temporal bone. The 
extreme intracranial pressure due to cerebral edema alone, 
successfully relieved by a bilateral subtemporal decompression. 



2Q4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

but much clear cerebrospinal 5. aid escaped; the cortex appeared "water- 
logged," bulged into opening and did not pulsate. Owing to this high 
cerebral pressure which could not be relieved by the one operation, a right 
subtemporal decompression was considered necessary. Usual closure with 
2 drains of rubber tissue inserted. Temporary sterile gauze dressing applied. 

Second Operation. — Right subtemporal decompression: usual vertical 
incision, bone removed and no complications; much free blood among the 
fibres of the temporal muscle beneath the temporal fascia and therefore a 
fracture of the underlying bone was to be expected, and it was found — being 
an oblique line of fracture extending from the right parietal bone downward 
through the upper portion of the underlying squamous bone. Upon remov- 
ing the bone, a small extradural layer of blood-clot — one-eighth inch in 
thickness — extended beyond the borders of the decompression opening and it 
was evacuated. Dura very tense and bulging, and upon incising it, clear 
cerebrospinal fluid again spurted but only to a height of 4 inches; upon 
enlarging the dural opening, the underlying cortex bulged but did not rup- 
ture ; no lacerations evident. Much clear cerebrospinal fluid escaped, allow- 
ing the cortex to recede slightly and to pulsate almost normally. Usual 
closure with 2 drains of rubber tissue. Duration, 85 minutes. 

Post-operative Notes. — Patient became conscious 12 hours after opera- 
tion, pulse ascended to 76, and although during the following 6 days patient 
was slightly confused mentally, irritable and restless, yet he made an un- 
eventful recovery so that he insisted upon ' ' going home ' ' 10 days after the 
operation ; incisions healed per primam. 

Examination at discharge (13 days after admission and 10 days after 
operation). — Temperature, 98.8° ; pulse, 80; respiration, 20; blood-pressure, 
128, Patient says he feels well, although "I have a little pain in my fore- 
head at times. ' ' Some mental retardation evident though no confusion, and 
patient is well oriented as to time, place and personality. Loss of memory 
for events of day preceding the injury (retroamnesia) — as is very common. 
No aphasia nor paraphasia can be elicited by the various tests. Both decom- 
pression areas bulging beyond the flush of scalp, but normal pulsation visible 
and palpable. Pupils equal and react normally. Reflexes : patellar very 
active — right possibly greater than left; no ankle clonus nor Babinski; 
abdominal reflexes present and equal. Fundi — retinal veins enlarged ; nasal 
halves of both optic disks obscured by edema, but temporal halves of disks 
clear and distinct. 

Treatment. — Patient insisted upon returning home ; besides the general 
hygienic measures, he was strongly advised to remain at home quietly and 
to attempt no work for a period of 3 months, at least. 

Examination (July 7, 1914 — 2 months after injury). — Temperature, 
98.8° ; pulse, 80; respiration, 20; blood-pressure, 134. No complaints other 
than a "sort of fulness in the head"; rather irritable at times and wants 
to return to work. Patient can now remember some of the events of the 
day preceding the accident (the usual recovery of memory that occurs in 
these patients). Both decompression areas slightly depressed; normal pul- 
sation. Reflexes active but otherwise negative. Fundi — slight haziness along 



ACUTE BRAIN INJURIES 295 

the lower nasal sector of both optic disks but the retinal veins are of 
normal size. 

Examination (September 20, 1916 — 28 months after injury). — Except 
that patient becomes more easily fatigued than formerly and then has an 
occasional headache, he has no complaints; works daily as a reporter and 
is apparently very successful. Both decompressions - ' sunken in " ; normal 
pulsation. Reflexes active but otherwise negative. Fundi negative. 

Last Examination (October 4, 1918 — 55 months after injury). — No 
complaints. "As strong as ever. " Both decompression areas depressed and 
their diameters have lessened owing to new bone formation about the periph- 
ery; only slight pulsation can be palpated. Reflexes active but otherwise 
negative. Fundi ngeative. 

Remarks. — This patient has been a most instructive case : the value of 
waiting until the signs of severe shock have disappeared before even a 
thorough examination is made and, by all means, the inadvisability of any 
operation during this period, are clearly illustrated; this patient would 
undoubtedly have died if an operation had been attempted during the period 
of extreme shock. The value of a bilateral decompression is also illustrated, 
as it is doubtful if the intracranial pressure of this patient could have been 
sufficiently relieved by a unilateral decompression alone ; however, if it had 
been realized (and it can be more accurately ascertained now by using the 
spinal mercurial manometer) that the intracranial pressure was so high, 
then a right subtemporal decompression (the patient being right-handed) 
would have been advised first to be followed by a left subtemporal decom- 
pression — even though the signs indicated (and they did in this patient) a 
more marked lesion of the left hemisphere; by performing a right sub- 
temporal decompression first in these patients, there is less danger of possible 
operative trauma producing its clinical signs — the right temporo-sphenoidal 
lobe being less highly developed in function than the left temporo-sphenoidal 
lobe and the contiguous cortex in right-handed individuals. Again, the 
immediate rise in pulse-rate following the operation and a lessening of 
the high intracranial pressure illustrate the effectiveness of the decom- 
pressions and also the avoidance of the dangerous medullary compres- 
sion of extreme degree. It is rather surprising that the fracture of the 
skull did not enter the nose, mouth or ears ; if it had there would undoubt- 
edly have been a definite lessening of the intracranial pressure by means of 
the escape of blood and cerebrospinal fluid through these channels of exit. 
It is remarkable that this patient has not been impaired mentally and par- 
ticularly emotionally, and patients of this character of excellent recovery 
should encourage us to avail ourselves of all means and not to lessen or delay 
our efforts in trying to obtain good results. 

In the treatment of shock following cranial injuries, there is possibly 
no one measure so effective and valuable as external warmth and heat applied 
to the entire body by means of heated blankets, hot-water bottles and hot 
rectal enemata and continuous warm irrigation. This patient was consid- 
ered moribund upon admission — the respirations being so shallow and im- 
perceptible that only 6 per minute were registered: on the contrary, the 
pulse was 144, whereas the temperature was only 97.4 and the blood-pres- 



296 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

sure 104 — signs of extreme shock, and the patient should be considered 
only from the standpoint of the condition of shock and so treated; if sur- 
vival occurs, then the associated cranial or bodily condition can be ascer- 
tained and treated accordingly. 

It is unfortunate in this patient, too, that a lumbar puncture with a 
removal of cerebrospinal fluid was not performed just before the dura was 
opened at the first operation ; this procedure would possibly have prevented 
the extensive laceration of the underlying cortex by lowering the intradural 
pressure, and the danger of performing a lumbar puncture at this time — 
the dura being opened — is practically nil, there being little or no danger 
of the medulla being forced down into the foramen magnum in supraten- 
torial lesions. 

Acute Severe Brain Injuries Associated with Extreme Shock and No 
Increase of the Intracranial Pressure; Naturally, No Operation. 
Death ; Autopsy. 

If the immediate shock of the cranial injury is severe, then the general 
blood-pressure is low — even 100 and below, so that it would be very difficult 
and practically impossible for a large intracranial hemorrhage to occur — 
even in the presence of a large intracranial vessel being torn (usually a 
sinus or cortical vein) owing to this lowered blood-pressure of shock; that is, 
the intracranial pressure would quickly become higher than this lowered 
blood-pressure of shock, so that no bleeding intracranially could then occur, 
and no large hemorrhage could result until the general blood-pressure is 
raised by the survival of the patient from this extreme condition of shock. 
Fortunately, this recovery from the shock results in many patients, and 
by the time it does occur the torn intracranial vessel or vessels have become 
thrombosed, so that, as the general blood-pressure does ascend upon the 
disappearance of the shock, yet very little intracranial hemorrhage results — 
apparently Nature's method of protecting the organism. 

These patients, therefore, in the extreme condition of initial shock rarely 
disclose the signs of an increased intracranial pressure and therefore no 
cranial operation of decompression is indicated — no matter how badly the 
skull may be fractured nor how certain approaching death may seem; 
a cranial operation in this period of severe shock takes away the chance of 
the patient to recover from the shock; and if the patient should recover, 
however, from the operation, then he does so in spite of the operation. 

In rare cases, where the shock immediately following the injury was 
slight and yet a large intracranial vessel was torn, then the intracranial 
hemorrhage may be so large that its rapid formation may precipitate an 
extreme condition of shock so that within a period of thirty minutes or an 
hour and before the patient reaches the hospital, the condition may be one 
of such extreme shock even in the presence of a high intracranial pressure 
that a cranial operation to relieve the increased pressure would be merely 
an added shock and the death of the patient would thus only be hastened. 
During the past five years, I have operated upon a number of these mori- 
bund patients (eight patients in all) — in extreme shock and in the presence 
of high increased intracranial pressure, and the percentage of recover}" 



ACUTE BRAIN INJURIES 297 

was 25 per cent, (two patients) ; I now feel that these patients would have 
recovered from the extreme condition of shock without an operation and 
then later the operation could have been more safely performed — that is, 
they recovered in spite of the operation ; also, of the six patients who died, 
possibly two of them and even three might have recovered from the severe 
condition of shock if an operation had not been attempted at the time 
it was performed, and therefore the operation may have been an important 
factor in their deaths. 

In conclusion, it can be stated that no patient in severe shock from a 
cranial injury should be operated upon — no matter how high the intracranial 
pressure is or seems to be, and that all therapeutic measures should be 
directed toward the recovery of the patient from the shock ; if this can be 
accomplished, then the cranial operation of decompression and drainage can 
be safely performed. Naturally, no patient, whether in severe shock or not, 
who does not exhibit the signs of a high intracranial pressure should be oper- 
ated upon — and especially a so-called "decompression" performed, as this 
operation presupposes the presence of an increased intracranial pressure and 
it surely cannot be a decompression if there is no increased pressure present. 
Many of the catastrophies of cranial surgery upon these patients have 
resulted from the neglect and oversight of this cardinal principle. 

If it is possible for the patient to recover from this severe condition 
of shock, then it will be observed that the subnormal temperature, lowered 
blood-pressure and increased pulse- and respiration-rates will gradually 
change until the temperature becomes normal and usually above normal, 
the blood-pressure rises and the pulse- and respiration-rates decrease to 
110 and 24 and below, respectively; now, and not until this time, is the ideal 
period for careful neurological examinations to be made and the intracranial 
condition ascertained as accurately as possible so that it will be known later 
whether the condition of the patient is really improving or not, and thus the 
appropriate treatment can be early instituted. 

Acute severe brain injuries with no increase of the intracranial pressure : 
no operation. Early death due to extreme shock. Autopsy. 

A. Fracture of the skull present. 

Case 58. — Acute severe brain injury with no signs of an increased intra- 
cranial pressure and in severe shock. No operation. Death. Autopsy. 

No. 97. — Hugh. Forty-four years. White. Married. Waiter. U. S. 

Admitted February 7, 1914, Polyclinic Hospital. Referred by Doctor 
Alexander Lyle. 

Died February 7, 1914 — 2 hours after admission. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was struck by a taxi- 
cab ; immediate loss of consciousness ; brought to the hospital in the taxicab. 

Examination upon admission (15 minutes after injury V — Tempera- 
ture, 98° ; pulse, 110 ; respiration, 30 ; blood-pressure, 114. Profound uncon- 
sciousness and in a severe condition of shock : cold, clammy skin with cold 
perspiration over the entire body; pulse scarcely perceptible, while respira- 
tions very shallow. Laceration of scalp over left parietal area. Slight 



298 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

bleeding from nose but not from mouth or ears ; much mastoid ecchymosis. 
Severe injury to chest with fracture dislocation of sternum and subcutaneous 
emphysema over entire chest and in both axilla?. Pupils dilated, left pos- 
sibly larger than right. Reflexes all abolished; corneal reflexes absent. 
Fundi negative. 

Treatment. — Vigorous shock measures instituted, especially external heat 
to entire body by means of warm blankets and hot-water bags, hot enemata 
of black coffee, brandy subcutaneously with atropine and strychnia hypo- 
dermically. Edema of the lungs appeared, however, within one hour and 
patient progressively became worse in that the temperature descended to 
97.2°, pulse ascended to 150 plus and respirations to 40 plus, while the 
blood-pressure fell to 80 and below. Patient died 2 hours after admis- 
sion from shock. 

Autopsy. — Linear fracture of the vault of 4 inches in length extended 
from posterior portion of left parietal bone forward and obliquely downward 

. ~p — ^^^^ toward left external orbital process, 

s^ J >v but it did not reach the base (Fig. 83). 

/ 4 >^ No extradural hemorrhage. Cerebro- 

($, Ml/ ^^'T'"'^; r '/£\ spinal fluid blood-tinged but no intra- 

/rhlL. (k-^y^^Z '''''> "*V/ *' Wm craina l hemorrhage nor cerebral 

\ Jm wms\ ^~~S ''"' '''wMM l acera tion could be ascertained — merely 

) ) >\ ^iBI W \ '■ wSliiM a ra ' tner P a ^ e anc ^ anemic brain with 

y ' ^^s^f^^Sx ''!/// mMmi mncn cerebrospinal fluid at the base. 

\Jl^J^mv^'?^^\\^9wF "Ventricles negative. 

WnvSt J ^ { I^qi^)^^^^/ Remarks. — Xo treatment whatever 

/ • ^ /( \ apparently could have caused the re- 

\J^ - — umt of FRAc-runn covery of this patient; these severe 

fig. 83.-wide linear fracture of left vault chest injuries associated with the cranial 

in a patient who died from shock; there was no ••,,,, r»7*nrhif»Pfl p rlpoTfp nf o }i n p k 

increase naturally of the intracranial pressure m J n1 ^ piOCLUCea. 8. degree 01 SHOCK 

and no intracranial hemorrhage was ascertained W hicll COuld not be Survived. The 
at autopsy. 

clinical history of subnormal tempera- 
ture and initial low blood-pressure, while the pulse and respration were 
never below 110 and 30, respectively, indicate the condition of true shock 
and for these patients naturally no operation of any severity, cranial 
or otherwise, can be considered, as operations at this stage are merely 
an added shock; if, however, the shock could be survived as indicated 
by an increase in temperature and blood-pressure and the lowering of 
the pulse- and respiration-rates, and, in addition, if the signs of an increased 
intracranial pressure of marked degree appear, then a cranial operation 
for the relief of the increased intracranial pressure may be considered — 
such as the subtemporal decompression. 

As the condition of severe shock presupposes a low blood-pressure, it is 
only in very rare cases of cranial injuries that the signs of a marked increase 
of the intracranial pressure are to be ascertained during this stage of 
severe shock; when the signs of intracranial pressure do appear in these 
patients, it indicates the lessening of the shock which permits the blood- 
pressure to rise and therefore the blood can be forced intracranially through 
any of the torn intracranial vessels. It is only when a large intracranial ves- 



ACUTE BRAIN INJURIES 299 

sel is suddenly torn as the result of a head injury that a high increase of the 
intracranial pressure can occur early, because these cases of head injury are 
all associated with a high degree of shock. If this patient had survived the 
shock, it is very probable that a larger intracranial hemorrhage would have 
occurred than was found at autopsy. 

The relative unimportance of the fracture of the skull in this patient is 
clearly demonstrated in that there was no underlying hemorrhage or cere- 
bral contusion, and it was just the same as if no fracture of the skull was 
present. If this fracture, however, had extended into the left middle ear 
so that the intracranial hemorrhage and the cerebrospinal fluid could have 
escaped through the left ear, then, if this patient had survived the condition 
of shock, this line of fracture would have been possibly a great benefit to the 
patient in permitting by means of this drainage a lessening of the increased 
intracranial pressure and thus avoiding the necessity of a cranial decom- 
pression. The fracture in this patient, however, was neither a benefit nor 
a harm to the patient. 

Case 59. — Acute severe brain injury with no signs of high intracranial 
pressure and in severe shock. No operation. Death. Autopsy. 

No. 148. — Ella. Twenty-three years. White. Single. Stenographer. U. S. 

Admitted July 8, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Died July 8, 1914 — 60 minutes after admission and 80 minutes 
after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While alighting from a street car, patient was knocked 
down by an automobile; immediate loss of consciousness; brought to the 
hospital in the automobile. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 97.4° ; pulse, 140 ; respiration, 36 ; blood-pressure, 90. Semiconscious 
and very restless ; severe shock. Compound comminuted fracture of left tibia 
and left fibula. No laceration or contusion of the entire scalp. Profuse 
bleeding from nose and both ears ; both mastoid areas, ecchymotic and both 
orbits swollen and ecchymosed. A discharge of cerebrospinal fluid from 
the nose and ears observed. Urine obtained by catheter negative. Pupils 
dilated but equal and react sluggishly to light. Reflexes — patellar increased, 
right more than left; no ankle clonus, but right Babinski ; abdominal 
reflexes absent. Fundi — retinal veins slightly enlarged; nasal margins of 
both optic disks not as clear and distinct as temporal margins. Lumbar 
puncture — blood-tinged cerebrospinal fluid under normal pressure (ap- 
proximately 7 mm. ) . 

Treatment. — Vigorous shock measures instituted, but patient became 
progressively worse in that temperature descended to 97°. pulse became more 
and more rapid until it was imperceptible and the respiration could not 
be counted, while the blood-pressure rapidly lessened until death occurred 
from the shock one hour after admission. 

Autopsy. — Fracture of base extended through middle fossa and both 
petrous bones into the tympanic cavities, and upward on the left side of the 



3 oo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



vault to the parietal crest. Both orbital plates of sphenoid bone also frac- 
tured (Fig. 84). Both tympanic membranes lacerated in their posterior 
halves. No extradural hemorrhage. Tip of left temporo-sphenoidal lobe 
and anterior surface of both frontal lobes contused and lacerated. Cerebro- 
spinal fluid blood-tinged and an occasional punctate hemorrhage throughout 
the cortex of both hemispheres, but no extensive hemorrhage intracranially 
could be found. Ventricles negative. 

Remarks. — It was remarkable that there were no external evidences upon 
the head of the area oi contact, and yet the fracture through the base was 
most extensive ; whatever bleeding occurred intracranially must have escaped 
through the fracture into the ears, although in the presence of such a 



CRISTA GALU 



LINES OF 
FRACTURE 




SELLA TURCICA 



FORAMEN OVALE 
POST. CLINOID PROC. 
BASILAR PROCESS 
INT. AUDITORY MEATUS 
PETROUS BONE 
JUGULAR FORAMEN 
FORAMEN MAGNUM 



Fig. 84. — Extensive basilar fractures of the middle and anterior fossae in a patient dying of extreme 
initial shock. Xo operation was performed as there could not be a high intracranial pressure in the presence 
of severe shock; any operation would have been merely an added shock to the patient. 

marked degree of shock, very little bleeding could have occurred intracran- 
ially. The increased reflexes, particularly upon the right side, and especially 
the right Babinski, were undoubtedly due to the greater cortical injury over 
the left hemisphere. In the presence of cortical contusions and lacerations 
as in this patient, if the shock could have been survived and thus the blood- 
pressure be increased, undoubtedly there would have been an extensive sub- 
dural hemorrhage which would become greater as the blood-pressure became 
higher and therefore the signs of an increased intracranial pressure would 
have become more and more evident. It is upon these moribund patients in 
shock that, formerly, cranial operations were frequently performed, because 
it seemed, and correctly so, that the patient was going to die, and yet any 
cranial operation upon these patients takes away whatever chance the 
patient has of surviving the shock, and if they should survive both the shock 
and the added burden of the operation, then they recover merely in spite 



ACUTE BRAIN INJURIES 301 

of the operation, and naturally they would have done so — and much more 
easily, if the operation had not been performed. 

Patients of this character in the extreme condition of shock require 
the most urgent treatment for the shock ; as external warmth is possibly the 
most important factor in the treatment of these shock patients, it would seem 
advisable and practicable that ambulances should be equipped both with 
hot water-bags and heated blankets so that these patients could receive 
appropriate treatment almost immediately. (A small electric heater in the 
ambulance would be sufficient for the blankets.) It is the transference 
of the patient from the street, sidewalk, or the floor, and usually ' ' chilled 
through," and then the ride to the hospital, especially in cold weather, 
the cursory examination in the accident-room — it is these delays and ex- 
posures before the patient reaches the ward and appropriate treatment that 
lessen the patient 's chances of recovery, and especially these patients having 
severe shock. 

It might be argued that patients of this type would have had a chance to 
recover if the operation of cranial decompression had been performed during 
the first hour or two after admission — because the patient died without an 
operation and therefore he might have lived if an operation had been per- 
formed. This argument can no longer be used in that we now know that no 
cranial operation should be advised in these acute cases, unless in the presence 
of a marked increase of the intracranial pressure (excluding naturally all 
cases of depressed fractures of the vault) ; this patient at no time showed 
the signs of an increased intracranial pressure and therefore no cranial 
operation, and particularly a decompression operation, was indicated. The 
escape of blood and cerebrospinal fluid from the nose possibly lessened any 
increase of the intracranial pressure that might have been present. 

The initial shock of this patient was apparently not so severe as in many 
patients who have survived, and for this reason it was believed that the 
patient would be able to recover from the shock. If the shock had been sur- 
vived and therefore an increase of the blood-pressure had occurred, the 
autopsy findings indicated that undoubtedly the intracranial pressure would 
have been markedly increased so that the operation of cranial decompression 
might have later been necessary. The absence, however, in this patient of a 
large intracranial hemorrhage is further evidence that the condition of shock 
prevents a large amount of intracranial bleeding which only occurs if the 
shock can be survived. When patients are in a severe condition of shock, the 
neurological examination should be a most cursory one, as the entire attention 
should be directed toward the treatment of shock, and prolonged examina- 
tions cause the patient to be exposed, body heat is lost which is most to be 
avoided and the patient is certainly not benefited as nothing really can be 
done for the patient until the shock has subsided — brain injury or not. 
The lumbar puncture, therefore, upon this patient was inadvisable during 
this period of shock and it should not have been performed ; the observation, 
however, that the pressure of the cerebrospinal fluid was only 7 mm. con- 
firms the opinion that in severe shock it is most rare for a high intracranial 
pressure to be present and, upon a physiological basis, practically impossible. 

The profuse discharge of cerebrospinal fluid from the nares and also 



3 o2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

through the line of fracture, as revealed at autopsy, in the cribriform 
portion of the ethmoid bone would have been an excellent channel through 
which an increased intracranial pressure could have been lessened, so that 
the patient would thus have "decompressed" himself; the danger of infec- 
tion, however, through this same line of fracture into the nasal cavity would 
have been very great indeed — possibly greater than in similar fractures 
through the middle ear. 

B. No fracture of the skull present. 

Case 60. — Acute severe brain injury with no signs of an increased intra- 
cranial pressure but in severe shock. No operation. Death. Autopsy. 

No. 100. — Arthur. Twenty-eight years. White. Single. Butler. England. 

Admitted January 9, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Died January 9, 1914 — 1 hour after admission and 95 minutes 
after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While cleaning a fourth-story window, patient fell to 
the pavement below ; immediate loss of consciousness ; brought to the hospital 
in the ambulance. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 97.2°; pulse, 150 plus; respiration, 40; blood-pressure, 82. Pro- 
found unconsciousness and in extreme shock ; moribund ; pulse imperceptible 
at times. Contusion over left eye ; left orbit ecchymosed. No bleeding from 
nose, mouth or ears; no mastoid ecchymoses. Fracture of pelvis — com- 
minuted left ilium. Pupils widely dilated and do not react. Reflexes all 
absent, except for slight cerebral reflex. Fundi negative. Abdominal ex- 
amination negative ; catheterized urine negative. 

Treatment. — Vigorous shock measures instituted. Patient rapidly be- 
came worse and died in a condition of extreme shock one hour after admission. 

The coroner's physician (Doctor Lehane) viewed the body at a distance 
of 10 feet, and, with the aid of the history, made the diagnosis of "fracture 
of the skull" and refused to perform an autopsy — "because the cause of 
death is evident. ' ' Permission, however, for the autopsy was later obtained 
from the relatives and it was accordingly performed. 

Autopsy. — No fracture of the skull could be found; no extradural 
hemorrhage. Blood-tinged cerebrospinal fluid with contusion of the anterior 
surface of both temporo-sphenoidal lobes and the inferior surface of the 
left frontal lobe ; otherwise the brain was negative. Very little cerebrospinal 
fluid in the cranial cavity. Ventricles negative. 

Remarks. — This patient undoubtedly died from shock not only from 
his general bodily injuries, particularly the fracture of the pelvis, but also 
the severe head injury which had caused the contusion of areas of the cerebral 
cortex ; no large intracranial hemorrhage was present, however, because the 
lowered blood-pressure of shock would not permit a large amount of intra- 
cranial bleeding in that the intracranial pressure was higher than this 
lowered blood-pressure of shock. 

The illogical and mediaeval diagnosis of ' ' fracture of the skull ' ' as being 



ACUTE BRAIN INJURIES 303 

the cause of death, or even being an important factor in the causation of 
death (if we except those patients dying from a meningitis through infection 
by way of the fracture itself, or those patients having large depressed frac- 
tures of the skull), can no longer be used as a satisfactory explanation of the 
cause of death of patients following a cranial injury ; the fractures of bones, 
of the extremities and of the trunk may be and are important in the treat- 
ment of these conditions, but it does not necessarily follow that in brain 
injuries the fracture of the skull is of any great importance — whether it is 
present or not. Considering brain injuries as being necessarily associated 
with fractures of the skull and thus indicating the method of their treat- 
ment — this conception has retarded the progress of the treatment of brain 
injuries possibly more than any other one factor, and the sooner we can 
consider brain injuries independently of the presence of a fracture of 
the skull, and more in relation to the presence or not of an increased 
intracranial pressure, just so much earlier will these patients obtain a more 
rational treatment and therefore the mortality be greatly lowered. 

Case 61. — Acute severe brain injury with no signs of increased intra- 
cranial pressure and in an extreme condition of shock. No operation. 
Death. Autopsy. 

No. 106. — John. Thirty-five years. White. Married. Storekeeper. U. S. 

Admitted January 12, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Died January 12, 1914 — 30 minutes after admission and 55 minutes 
after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient fell from a platform in the subway and was 
struck by a train ; immediate loss of consciousness ; brought to the hospital 
in the ambulance. 

Examination upon admission (25 minutes after injury). — Tempera- 
ture, 97.2°; pulse, 118; respiration, 32; blood-pressure, 106. Profound 
unconsciousness, but became conscious for 15 minutes sufficiently to realize 
his condition and then became again unconscious ; in severe shock. Stellate 
lacerations of the scalp over left frontal area and above left eye ; left orbital 
ecchymosis. No bleeding from nose, mouth or ears ; no mastoid ecchymoses. 
Pupils widely dilated and do not react to light. Reflexes all absent, including* 
corneal reflexes. Fundi negative. 

Treatment. — Vigorous shock measures instituted. Patient, however, 
became progressively worse — the pulse- and respiration-rates ascending to 
150 plus and 50 plus, respectively, until imperceptible, while the blood-pres- 
sure sank lower and lower until it could not be registered ; death occurred SO 
minutes after admission. (The ambulance surgeon stated that at the time 
the patient was carried into the ambulance the pulse was 66 while the respira- 
tion was only 8 — that is, the stage of acute medullary compression ; this 
observation could not be confirmed, however, by the autopsy findings.) 

Autopsy. — (Permission was received from relatives after the coroner's 
physician, Doctor Weston, had refused to perform an autopsy since "the 
diagnosis is evident from the history," and, "the scalp wounds and the black 



304 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

eye indicate a fracture of the skull. " ) No fracture of the skull ascertained ; 
no extradural hemorrhage. Brain itself very "wet"' and edematous but no 
cortical hemorrhages or lacerations could be found. Slightly blood-tinged 
cerebrospinal fluid, especially in the middle fossa. Medulla negative. Ven- 
tricles negative. Subtentorial fossa negative. 

Remarks. — The initial shock of this patient was sufficient in itself appar- 
ently to cause death, and yet the autopsy findings hardly account for the 
death — especially in a man apparently in good health under middle age. 
If this patient could have received the ideal shock treatment immediately 
after the injury instead of lying upon the cement floor of a subway station 
for a period of 20 minutes, it might have been possible to have obtained a 
recovery; there was no evidence of chronic alcoholism, although the man 
was a rather heavy-set, obese patient, yet ordinarily the shock might have 
been survived. It was unfortunate that permission for a complete autopsy 
of the body was not obtained, for possibly there were other internal injuries 
of the abdomen or chest that would have explained the death of this patient. 

The absence of definite signs of pressure about or in the medulla and sub- 
tentorially in the autopsy findings is rather puzzling in view of the observa- 
tion of the ambulance surgeon that the patient upon admission to the ambu- 
lance had a pulse-rate of 66 and a respiration-rate of only 8 — the typical 
ratio of pulse- and respiration-rates in acute medullary compression; the 
medulla, however, was of normal appearance and consistency so that it is 
very difficult to explain this observation as being due to a medullary dis- 
turbance. The blood-pressure would have been an interesting observation 
at this period ; if high or even slightly increased, it would tend to confirm a 
diagnosis of medullary compression, whereas if low then the condition of 
shock and other extracranial lesions might be considered ; in either case, how- 
ever, it is very difficult to explain, and it is very unfortunate that permission 
for a complete autopsy was not obtained. 

Acute Severe Brain Injuries Associated with an Extreme Intra- 
cranial Pressure Precipitating an Acute Medullary Edema. No 
Operation. Death; Autopsy. 

The acute medullary edema occurring in these patients following a cranial 
injury with and without a fracture of the skull is due to an extreme intra- 
cranial pressure, either of hemorrhage or of an excess amount of cerebro- 
spinal fluid (cerebral edema). This increase of intracranial pressure may 
occur so rapidly following the cranial injury that the symptoms and signs of 
shock merge quickly into those of medullary edema — at times apparently 
without passing through the clinical stages of medullary compression — that 
is, the subnormal temperature, low blood-pressure and increased pulse- and 
respiration-rates of severe shock quickly become changed, as the result of a 
very early and extreme intracranial pressure, to a high temperature, and 
even higher pulse- and respiration-rates of medullary edema without show- 
ing clinically the signs of a preceding medullary compression — slightly 
increased temperature, an ascending blood-pressure and descending pulse- 
and respiration-rates to 60 and 16, respectively, and lower. Formerly, many 
of these patients succumbing to an early medullary edema were believed to 



ACUTE BRAIN INJURIES 305 

have died from the condition of extreme shock as the more modern 
methods of determining this increased intracranial pressure by means of the 
ophthalmoscope and the spinal mercurial manometer were not in common use, 
and therefore the true intracranial condition was overlooked ; these cases can 
now be easily differentiated clinically, and if an autopsy is performed (and 
permission for it should always be obtained), the diagnosis of medullary 
edema resulting from the high intracranial pressure can thus be confirmed. 

In the patients who recover from this shock of varying degree and then 
exhibit the signs of an increasing and high intracranial pressure, unless this 
increased intracranial pressure — it matters not whether due to hemorrhage 
or edema — is relieved early and thus the signs of medullary compression 
are lessened, then the great danger of a medullary edema is to be feared; 
for if once the lowered pulse- and respiration-rates and increased blood- 
pressure of medullary compression quickly change to the high and increasing 
pulse- and respiration-rates and descending blood-pressure of medullary 
edema, then that patient will die — operation or no operation — within 24—36 
hours. It is of the greatest importance, therefore, that these patients should 
be carefully and repeatedly examined in order to estimate accurately the 
true intracranial status and especially in regard to an increasing intracranial 
pressure ; if the expectant palliative method of treatment does not prevent 
the intracranial pressure from increasing, then its early lowering by means 
of a subtemporal decompression and drainage, and if necessary, a bilateral 
decompression is advisable. 

Acute severe 'brain injuries associated with high intracranial pressure 
precipitating medullary edema. No operation. Death. Autopsy. 

A. Fracture of the skull present. 

a. High intracranial pressure due to a large intracranial hemorrhage. 

Case 62. — Acute severe brain injury associated with high intracranial 
pressure due to subdural hemorrhage and cerebral edema. No operation. 
Medullary edema; death. Autopsy. 

No. 140. — James. Fifty-five years. Married. Horse-shoer. Ireland. 

Admitted April 2, 1914, Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Died April 2, 1914 — 9 hours after admission and 10 hours after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was found lying upon the sidewalk; uncon- 
scious ; brought to the hospital in the ambulance. 

Examination upon admission (at least one hour after injury). — Tem- 
perature, 102.6° ; pulse, 90; respiration, 28; blood-pressure, 140. Profound 
unconsciousness ; odor of alcohol upon breath — giving the house surgeon the 
impression that patient was merely alcoholic. Small hematoma of contact 
over left occipital area. No bleeding from nose, mouth or ears. Slight spas- 
ticity of left arm and left leg. Pupils — right dilated while left pupil very 
much contracted and no reaction to light. Reflexes: patellar — left greater 
than right; suggestive left Babinski but no ankle clonus: abdominal reflexes 
absent. Fundi — retinal veins dilated ; nasal halves of both optic disks 
slightly blurred, but as there was a profuse congestion of both retinae, it was 



3 o6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

at the time considered as being due to chronic alcoholism. No lumbar punc- 
ture performed as it was considered unnecessary (an unfortunate mistake). 

Treatment. — Expectant palliative. 

Examination (4 hours after admission). — Temperature, 103° ; pulse, 60; 
respiration, 16 ; blood-pressure, 140. General condition of the patient prac- 
tically the same except that the pulse- and respiration-rates were descending 
and the signs of intracranial pressure as registered upon the fundi were 
increasing. Definite left mastoid ecchymosis. Pupils — both dilated and do 
not react to light. ' Reflexes : patellar — both exaggerated, right possibly 
more than left ; double Babinski and exhaustible ankle clonus ; abdominal 
reflexes absent. Fundi — retinal veins dilated; nasal halves of both optic 
disks blurred and the temporal margins were obscured by edema. Lum- 
bar puncture — bloody cerebrospinal fluid under increased pressure 
(approximately 17 mm.). 

Treatment. — The expectant palliative treatment was continued in the 
hope and belief that the patient himself would be able "to take care of" 
this increased pressure and thus an operation be avoided. (The operation, 
however, should have been performed at this time while the pulse was 
descending and before the lowest pulse-rate of medullary compression had 
occurred. ) The patient continued in practically the same condition for two 
hours when he suddenly became worse, in that the temperature became 
103.6°; pulse, 100; respiration, 24; blood-pressure 130 — that is, the pulse- 
rate ascending rapidly while the blood-pressure was descending — the typical 
signs of medullary edema. The patient was hurried to the operating room 
in the mistaken belief that an immediate subtemporal decompression might 
cause a recovery of life, but the pulse ascended so rapidly to 150 plus while 
the blood-pressure descended to below 100 that the patient died before the 
operation could be begun. 

Autopsy (Doctor C. A. Schultze). — Large hematoma evenly distributed 
over entire right temporo-parietal area. Line of fracture began in the left 
occipital area (underlying the point of contact) and extended horizontally 
around the skull — on the left side to the left external orbital process and 
on the right side to a point one inch above the right external auditory canal 
(Figs. 85 and 86). Small hemorrhage beneath the torn periosteum of right 
orbital plate, but orbital bone itself intact. Middle ears negative. No epi- 
dural clot. Dura was intact — even under the line of fracture. Very large 
subdural clot over entire right hemisphere — about 16 ounces in amount and 
almost the size of a small grapefruit, Numerous supracortical clots and 
cortical lacerations of both anterior frontal lobes and also the tips of both 
temporo-sphenoidal lobes — more on the right side; extensive lacerations of 
right temporal lobe. No subtentorial hemorrhage. Ventricles negative. 

Remarks. — If this patient could have been treated early by means of a 
right subtemporal decompression and while the pulse-rate was descending, 
he might have been given a definite chance of recovery. The autopsy find- 
ings are most instructive in that such a huge subdural hemorrhage of almost 
4 inches in diameter could be present in the right parietotemporal area, and 
yet the only localizing signs of its presence, beside the signs of increased 
intracranial pressure which were not marked nor extreme, were the slight 



ACUTE BRAIN INJURIES 



307 



spasticity of the left arm and left leg and the increased reflexes of the left side 
and a suggestive left Babinski at first, while the left pupil was dilated in 
the beginning. These findings merely illustrate in a small way the great 
difficulty of localizing accurately small acute lesions of the brain when not 
situated in the motor cortex, and also to emphasize again that it is not so 
important to localize the lesion from an operative standpoint if an early 
subtemporal decompression is only performed upon the side of the hemis- 
phere over which the greater hemorrhage has occurred, and also that, in the 
usual case, it is more a question of lowering the increased intracranial pres- 
sure whether due to hemorrhage or cerebral edema; naturally in this 
patient, who is, I believe, an exception, it would have been most important to 
have drained the hemorrhage itself, and undoubtedly that "Would have 
been done if the right subtemporal decompression had been performed 
as planned. 

This case also emphasizes the importance of examining these patients 




LlNtSOFFRACTUHE 




Figs. 85 and 86. — Tremendous linear fracture extending horizontally around the posterior half of 
the vault in a patient developing an acute and early edema of the medulla, due to an extreme intracranial 
pressure. A decompression operation performed during the stage of medullary compression might have 
offered this patient a chance of recovery. 

early and frequently by the most accurate methods now known of determin- 
ing an increased intracranial pressure by considering the entire clinical pic- 
ture of pulse- and respiration-rates, blood-pressure, pupillary inequality 
and — most important — repeated ophthalmoscopic examinations of the fundi 
and the measurement of the pressure of the cerebrospinal fluid at lumbar 
puncture by means of the spinal mercurial manometer. Also to put us upon 
our guard that merely because a patient has the odor of alcohol upon his 
breath — this fact should not make us feel that the patient is unconscious 
because drunk, but most careful examinations should be made and the fact 
borne in mind that if there is any cranial lesion and if the patient in addition 
is drunk, then in the presence of an increaesd intracranial pressure not only 
does the alcoholism tend to mask the symptoms and signs of the intracranial 
lesion but to render the patient much more susceptible to the onset of an 
acute medullary edema; and therefore this great danger should always be 
most carefnlty considered. If a lumbar puncture had been performed at the 
time of this patient's admittance to the hospital, and this is usually done 
unless the patient is in shock, and this patient was not in shock, then the 
presence of blood wonld have been ascertained in the cerebrospinal thud 



3 o8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and this patient would naturally have received much more careful treat- 
ment in that the gravity of the condition would have been realized early; 
also, if an early X-ray picture had been taken, the line of fracture would 
undoubtedly have been revealed so that the factor of alcoholism would not 
have appeared to be such an important one in the case ; it is very probable 
that the true condition of this patient would have been early recognized and 
especially by means of the lumbar puncture with a measurement of the pres- 
sure of the cerebrospinal fluid, so that a right suptemporal decompression 
might have been sufficient to have obtained an excellent recovery. 

Case 63. — Acute severe brain injury associated with extreme intracranial 
pressure due to subdural hemorrhage and cerebral edema. No operation. 
Medullary edema ; death. Autopsy. 

No. 138. — Lorenzo. Forty years. White. Married. Ironworker. Italy. 

Admitted April 7, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Died April 7, 1914 — 7 hours after admission and 8 hours after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was found lying upon the sidewalk; uncon- 
scious; brought to the hospital in the ambulance. 

Examination upon admission (at least an hour after injury). — Tem- 
perature, 102.4° ; pulse, 150 ; respiration, 32 ; blood-pressure, 112. Profound 
unconsciousness with the patient in a moribund condition of medullary 
edema. Well-developed robust man ; chronic alcoholism. Small hematoma 
over left occipital region with extensive left mastoid ecchymosis. Profuse 
bleeding from nose. Occasional twitchings of both arms which are slightly 
spastic. Respiration irregular but shallow. Pupils dilated, equal and do 
not react to light. Reflexes all abolished, except corneal reflex. Fundi — 
retinal veins dilated; nasal halves of both optic disks obscured by edema. 
Lumbar puncture — bloody cerebrospinal fluid under high pressure — acci- 
dentally spurted a distance of 2 feet ( approximately 24 mm. ) , Urine — large 
trace of albumen with many hyaline and granular casts and a slight trace 
of sugar. 

Treatment. — Expectant palliative. The condition was considered one of 
acute medullary edema, but patient was carefully ' ' watched ' ' in the forlorn 
hope that his condition might be improved. Within one hour after admis- 
sion, both fundi revealed double "choked disks" — the left having a swell- 
ing of 4 diopters while the right was 3 diopters of swelling; retinal veins 
became tortuous and obscured by the retinal edema. Two hours after 
admission, a double Babinski appeared and the hematoma over left occipital 
area increased in size until it infiltrated the entire posterior portion of the 
scalp and the left side of head. The pulse gradually became imperceptible, 
edema of the lungs occurred and the patient died 7 hours after admission. 

Autopsy (Doctor C. A. Schultze). — Large subpericranial hematoma over 
entire portion of left side and back of head. Main fracture extended trans- 
versely around the entire posterior portion of the skull and into both mastoid 
bones (Figs. 87 and 88) ; another line of fracture extended from the occipital 
protuberance forward in the median line for a distance of about 4 inches. 



ACUTE BRAIN INJURIES 



309 



Dura intact with no extradural hemorrhage. Many subdural clots, espe- 
cially over temporo-sphenoidal lobes, and anterior surface of both frontal 
lobes. Extensive lacerations of both temporo-sphenoidal lobes, especially 
right. Brain itself very swollen and edematous and typically "water- 
logged." No subtentorial hemorrhage nor evident direct compression of 
the medulla. Hemorrhage in left middle ear, although tympanic membrane 
intact and no fracture of left petrous bone, but the overlying periosteum 
was torn — that is, it is possible to have a hemorrhage into the middle ear 
without there necessarily being a fracture of the contiguous portion of the 
petrous bone. 

Remarks. — It*would have been foolhardy to have advised an operation 
upon this patient because the signs of extreme medullary edema were already 
present, and any operation, no matter how slight, would have merely has- 
tened the exitus. Such patients are doomed — operation or no operation. 

The absence of direct medullary compression subtentorially in this patient 




U1NE OF FHACTURt 




Figs. 87 and 88. — Tremendously wide horizontal linear fracture of the posterior half of the vault in 
a patient whose extreme intracranial pressure of subdural hemorrhage and cerebral edema had precipi- 
tated an acute medullary edema at the time of his admission to the hospital. Expectant palliative treat- 
ment in the hope that a recovery might be possible; naturally, no operation. 

indicates that the supratentorial pressure must have been exceedingly high 
to have produced the signs of medullary edema so early, as the condition 
of medullary edema was very much advanced, even at the time of admission 
of the patient. 

The presence of bilateral spasticity, and particularly of both arms and 
legs in these patients, indicates a most serious intracranial condition of 
compression and edema of the pyramidal tracts in the internal capsule and 
in the medulla itself, and its existence usually indicates the condition of 
medullary edema and an early death of the patient. Each patient who has 
developed this condition of bilateral spasticity, with or without convulsive 
seizures in this series of patients, has died from an early medullary edema ; 
this condition of spasticity frequently occurs after the onset of the medul- 
lary edema and is merely another bad prognostic sign. 

The frequent laceration of either temporo-sphenoidal lobe, and espe- 
cially their tips, is usually a latent condition, and in no way, I believe. 
complicates the prognosis providing the increased intracranial pressure due 
to the consequent hemorrhage and cerebral edema is relieved. The inferior 
and anterior portions of both frontal lobes are similarly affected, but not so 



3 io DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

frequently as the anterior tips of the temporo-sphenoidal lobe. It must 
always be remembered, however, that it is not these cerebral lacerations 
which cause the death of the patient, but it is the unrelieved intracranial 
pressure resulting from the brain injury; if this intracranial pressure is 
lessened to within normal physiological limits, then these lacerations of the 
so-called ' ' silent ' ' areas of the brain will take care of themselves. 

It is rather unusual for the signs of increased intracranial pressure to 
progress so rapidly as they did in this patient during the stage of medullary 
edema — particularly is this true of the ophthalmoscopic findings in that 
"choked disks" developed within one hour after admission of the patient 
to the hospital and having a measurable swelling of 4 diopters. The sub- 
pericranial hematoma undoubtedly enlarged as a result of blood escaping 
through the underlying fracture of the vault, but this means of natural 
decompression was not of sufficient amount to prevent the intracranial pres- 
sure from increasing rapidly. 

Case 64. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to subdural hemorrhage and cerebral edema. No 
operation. Medullary edema ; death. Autopsy. 

No. 421. — Henry. Forty-two years. White. Married. Salesman. U. S. 

Admitted October 27, 1915, Polyclinic Hospital. 

Died November 17, 1915 — 21 days after admission and injury. 

Family history negative. 

Personal history negative, except for chronic alcoholism — becoming drunk 
at least once a month. 

Present Illness. — Patient was found lying unconscious at the bottom 
of a stairway ; brought to the hospital in the ambulance. 

Examination upon admission (at least one hour after injury). — Tem- 
perature, 97.4°; pulse, 88; respiration, 24; blood-pressure, 118. Poorly 
nourished; unconscious and in severe shock. No bleeding from nose or 
mouth, but profuse hemorrhage from both ears; left mastoid ecchymosis. 
Pupils slightly enlarged and do not react to light. Reflexes all absent. No 
ophthalmoscopic examination or lumbar puncture performed on account 
of the severe shock. 

Treatment. — Expectant palliative. The pulse gradually descended from 
88 to 62, while the blood-pressure increased to 148 and the temperature 
to 100.6°, and they remained practically in this same ratio for the following 
4 days when the pulse ascended to 92, where it remained until the consul- 
tation. Patient became conscious on the fifth day after admission and 
apparently improved daily. Two days ago, however, the patient became con- 
fused mentally, mildly delirious and rapidly became worse, so that acute 
delirium tremens w T as suspected. 

Examination (for the first time at consultation, on November 8, 1915 — 
12 days after admission). — Temperature, 101.8° ; pulse, 90; respiration, 26; 
blood-pressure, 124. Poorly nourished ; extremely restless and continuously 
talking in a mildly delirious condition. Although patient had been accus- 
tomed to the daily use of alcohol, since entering the hospital patient had not 
received alcohol in any form. Definite right facial paralysis of cortical 
type (muscles of right forehead not being involved) ; no weakness of right 



ACUTE BRAIN INJURIES 311 

arm or of right leg. Otoscopic examination of both ears — both tympanic 
membranes lacerated in their posterior halves. Pupils — left dilated, both 
irregular and do not respond to light. Reflexes : patellar active — right pos- 
sibly more active than left ; no ankle clonus, but tendency to right Babinski ; 
abdominal reflexes cannot be elicited. Fundi — retinal veins dilated; nasal 
halves of both optic disks obscured by edema — left more than right. Lum- 
bar puncture — bloody cerebrospinal fluid under high intracranial pressure 
(approximately 19 mm.). During the examination, the patient was contin- 
uously picking at the bed-clothes (carphologia) and looking anxiously about 
as though in a m/ld terror. Diagnosis was fracture of the skull (base) 
with an increased intracranial pressure due to cerebral edema (predisposed 
by alcoholism) and a possible intracranial hemorrhage; delirium tremens. 

Treatment. — Owing to the complication of chronic alcoholism with the 
signs of a mild delirium tremens appearing, the expectant palliative treat- 
ment was considered advisable — the patient to receive small amounts of 
alcohol frequently and the general treatment of chronic alcoholism with its 
acute manifestations should be administered. In spite of this treatment, 
however, the patient neither improved nor became markedly worse until 
9 days after consultation, when the temperature suddenly ascended to 107 
plus, pulse 150 plus, respirations 40 plus, while the blood-pressure descended 
to below 80, so that the patient consequently died — 9 days after consultation 
and 21 days after injury. 

Autopsy. — Liver was of the typical hobnailed character. Kidneys small 
and white. Lungs — entire right apex filled with tubercles, which were also 
scattered throughout the upper portions of both lungs. Heart negative. 

Cranial. — Line of fracture extended from left occipital bone forward 
and downward obliquely through left mastoid bone and then along the 
petrous portion to the sella turcica ; no fracture of the right petrous bone 
found (Figs. 89 and 90). Left hemisphere covered by a thin layer of sub- 
dural blood while the brain itself together with the cerebellum and the 
medulla was very much swollen, edematous and ' ' water-logged. ' ' Ventricles 
negative. No intracerebral hemorrhage or cortical laceration ascertained. 
Pathological diagnosis : fracture of skull, subdural hemorrhage, cerebral 
edema due to head injury associated with chronic alcoholism, pulmonary 
tuberculosis and chronic nephritis. 

Remarks. — As the autopsy findings indicate, this patient apparently 
had little chance of recovering from a severe brain injury — operation or no 
operation. It was only within the first 4 days following the injury when the 
pulse had descended to 62 and had remained there for 4 days while the 
blood-pressure had risen to 148, and there being present the other signs of 
an increased intracranial pressure — it was only during this period that 
an operation of subtemporal decompression could have been consid- 
ered advisable. 

It would seem that the condition of chronic alcoholism had been the 
more important factor in this patient and that it should have been giveD 
more importance in the treatment, To patients of middle age who have 
been accustomed to taking a daily amount of alcohol and then larger quanti- 
ties at irregularly frequent intervals, the deprivation of their daily allow- 



3 i2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

ance of alcohol is of great importance to their bodily functions, and the 
danger of withdrawing suddenly their daily allowance is so great for fear 
of precipitating both physical and emotional disturbances that it is of the 
utmost importance that these patients receive small and frequent doses of 
alcohol daily. Once the signs of mild delirium tremens occur in patients 
having had brain injuries, then it is usually too late to prevent the progress 
of the condition, although in this particular patient, the conditions progressed 
very slowly and it was not until the day of death that hope was given up of 
the patient 's recovery. Repeated lumbar punctures might have been of great 
value to this patient in that the shock of such a procedure was practically nil, 
and after the withdrawal of cerebrospinal fluid from patients having acute 
' ' wet ' ' brains due to chronic alcoholism and the allied toxic conditions, very 




FRACTURE. 



UNE. OF FHACTUBt 




Figs. 89 and 90. — Extensive linear fracture of left occipital and the petrous portion of the left temporal 
bones in a patient developing an acute medullary edema upon the twelfth day following the cranial injury. 
Beside the cranial injury, it was ascertained at autopsy that the resistance of the patient had been lowered 
by the effects of chronic alcoholism, pulmonary tuberculosis and chronic nephritis. 

frequently a marked improvement results — even if only of temporary dura- 
tion ; in selected patients, daily repeated lumbar punctures may be of per- 
manent value to the patient in lessening the delirium and extreme restless- 
ness, and even making it possible for their nourishment . to be taken with 
little or no difficulty. 

After the first 4 days following the patient's admission to the hospital, 
a subtemporal decompression or any operation of major character would 
have, in my opinion, resulted in the earlier death of the patient, and if any 
operation at all was to have been performed, it should have occurred within 
the 4 days following the patient's admission and after the signs of initial 
shock had disappeared. 

It was very interesting at the autopsy to elicit a fracture of the skull 
only of the left petrous bone and not of the right petrous bone, although the 
right tympanic membrane had been lacerated and a profuse discharge of 
blood had occurred through the opening ; this observation again emphasizes 



ACUTE BRAIN INJURIES 313 

the point that a mere laceration of the tympanic membrane and discharge 
of blood from the ear, and no cerebrospinal fluid observed, does not pre- 
suppose the existence of a fracture of the adjacent bones of the ear — it is 
only when cerebrospinal fluid is observed in the discharge from the ear 
that a fracture of the petrous bone can be said to have occurred. In this 
patient, the bleeding from the right ear undoubtedly resulted from the 
laceration of the right tympanic membrane itself, but it is difficult to con- 
ceive of the right tympanic membrane being lacerated without a fracture of 
the adjacent bones having occurred and yet no such fracture could be 
ascertained by most careful examination. Bleeding into the middle ear can 
occur without a fracture being present and the tympanic membrane intact, 
similar to orbital and subconjunctival ecchymoses and no fracture of the 
orbital bones being present ; there is frequently, however, a tear of the sur- 
rounding periosteum or of the dura over the bones in these patients. 

This is another case of direct medullary compression resulting in an 
early medullary edema which occurred so rapidly and before the signs of 
shock had disappeared that it was impossible to perform an operation for 
the relief of the pressure. It has been my experience that if these early 
patients with head injuries have a lowered temperature and blood-pressure, 
and yet the pulse is also lowered, then the condition of direct medullary 
compression should be considered as the factor complicating the initial 
shock following the injury. Naturally, it would be unwise during this period 
of shock to perform any operation to relieve medullary compression because 
the death of the patient would result from the added shock of the operation 
itself; and if this condition of shock merges directly into the condition 
of medullary edema without passing clinically through the stage of medul- 
lary compression, then also is an operation not to be considered because 
it would be of no value in retarding the progress of medullary edema 
— in fact, it would merely hasten it. But if the patient recovers from the 
condition of shock so that the temperature rises to normal and above, and 
the blood-pressure ascends to over 120, and yet the pulse remains low and 
there are present the other signs of an increased intracranial pressure as 
revealed by the ophthalmoscope and the spinal mercurial manometer, then 
this is the stage for the operation of decompression to be performed ; that is, 
these patients must be most carefully watched and frequently examined — 
the pulse, respiration and blood-pressure being taken every 30 minutes, and 
as soon as the shock disappears, then the use of the spinal mercurial mano- 
meter at lumbar puncture and the frequent examination of the fundi with 
the ophthalmoscope. 

The autopsy findings are interesting in that the early contraction to 
pin-point of the left pupil and the paresis of the right arm and right face 
were due to the subdural hemorrhage overlying the left cortex, and as the 
hemorrhage increased in size beyond the irritative stage, the left pupil 
became dilated from the paralytic effect of a large supracortical ami ipso- 
lateral hemorrhage; a complete paralysis of the right side of the body Avas 
not demonstrated. 

It is fortunate that a lumbar puncture had not removed much of the 
spinal fluid at the first examination, as it might have been considered a 



3 i4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

factor in precipitating the acnte medullary edema, especially in view of the 
autopsy findings in the subtentorial fossa ; the repeated lumbar punctures 
were performed after the medullary edema had become advanced. 

o. High intracranial pressure due to cerebral edema alone, and no intra- 
cranial hemorrhage present. 

Case 65. — Acute severe brain injury associated with high intracranial 
pressure due to cerebral edema. No operation. Medullary edema; 
death. Autopsy. 

No. 533.— Edward. Twenty-two years. White. Single. Clerk. U. S. 

Admitted March 21, 1916, Polyclinic Hospital. 

Died March 21, 1916 — 3 hours after admission and 3% hours after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While delivering a package at the side door of a house, 
patient tripped over a chain, falling backward to the ground upon his head ; 
no loss of consciousness but complained of severe pain throughout the head ; 
brought to the hospital in the delivery wagon. 

Examination upon admission (35 minutes after injury). — Tempera- 
ture, 98°; pulse, 38; respiration, 14; blood-pressure, 132. Semiconscious, 
but became unconscious within 30 minutes after admission. No bleeding 
from nose, mouth or ears ; no mastoid ecchymoses. Pupils equal, moderately 
contracted and reacted to light sluggishly. Reflexes — patellar moderately 
increased but equal ; no ankle clonus nor Babinski ; abdominal reflexes were 
equal but depressed (within one-half hour they could not be elicited). 
Fundi — retinal veins slightly enlarged ; both optic disks clear and distinct — 
there being no signs of an increased intracranial pressure. Lumbar punc- 
ture — slightly blood-tinged cerebrospinal fluid under high intracranial 
pressure (approximately 18 mm.) ; (the blood was apparently a contamina- 
tion of the puncture as it was not mixed evenly throughout the cerebro- 
spinal fluid). 

Treatment. — Owing to the signs of extreme intracranial pressure as 
registered by the very slow pulse- and respiration-rate and also at the lum- 
bar puncture, preparations for an immediate operation were made in the 
hope that a medullary edema would not be precipitated by these signs of 
high medullary compression. In the meantime, the patient was admitted to 
the ward, head prepared for operation, 6 ounces of hot black coffee adminis- 
tered per rectum, camphor in oil (grains 5), atropine (grains }4o) hypoder- 
mically, and hot water-bags and heated blankets applied to body ; 16 ounces of 
urine were removed by catheter. The condition of the patient, however, 
rapidly became worse; the temperature descended to 97° (rectal), the pulse 
ascended to 48 within an hour and to 72 within an hour and a half, and to 140 
within 2 hours after admission, while the respiration increased correspond- 
ingly up to 42 ; the blood-pressure descended as low as 78. These signs of 
medullary edema progressed so rapidly that an operation was not attempted 
and the patient died 3 hours after admission — the heart continuing to beat 
fully 4 minutes after the respiration had ceased. 

The coroner's physician, Doctor T. D. Lehane, after hearing the history 
and taking one glance at the body in the hospital morgue, made the diag- 






ACUTE BRAIN INJURIES 



3i5 



nosis of ' ' fracture of the skull with intracranial hemorrhage ' ' and refused 
to perform an autopsy; there were no external evidences of head injury 
and yet this learned consultant could make his diagnosis without even touch- 
ing the body — let alone performing an autopsy. Fortunately, however, the 
parents of the boy insisted that the cause of death should be accurately 
ascertained, as even the laity are becoming less and less impressed by the 
ability of doctors, as well as of coroner's physicians, to make "snap" diag- 
noses. At the urgent request, therefore, of police headquarters, Doctor 
Lehane did perform an autopsy the following morning at the city morgue 
to which the body had been taken. • 

Autopsy. — Left temporal muscle very hemorrhagic and there was found 
a small linear fracture of the underlying left squamous bone about 4 cm. 
in length (Fig. 91). The dura was not torn and there was no subdural nor 
cerebral hemorrhage, but the brain itself was very much swollen and edem- 
atous — the typical "wet," "water- 
logged" brain. Ventricles nega- 
tive. A little cerebrospinal fluid 
was slightly blood-tinged but there 
was not sufficient blood to cause an 
increased intracranial pressure. 
The medulla itself was swollen and 
edematous. No other injuries to 
the brain or skull were demon- 
strable at autopsy. 

Remarks. — This case is most 
instructive in that it illustrates 
again that an acute medullary com- 
pression and its resulting edema 
can occur in brain injuries, even 
in young adults, and of sufficient 
degree to cause death even in the 
absence of an intracranial hemorrhage. This extreme condition is unusual, 
I believe, in young adults without there being associated with it an intra- 
cranial hemorrhage; it more frequently occurs in patients beyond mid- 
dle age and especially in those patients of lessened resistance due to chronic 
alcoholism and its allied conditions of arteriosclerosis and nephritis. If 
the condition of this patient could have been retarded so that the onset of 
medullary edema would have been delayed for a period of 2 hours or more, 
it is possible that a subtemporal decompression, and if necessary, a bilateral 
decompression would have sufficed to obtain a recovery of life — especially 
since the patient was a youthful adult and apparently in good health at 
the time of the injury. 

I mentioned the details of the coroner's examination chiefly for the 
purpose of illustrating the difficulties, at times, of securing an official per- 
mission for performing a post-mortem examination upon these patients. 
The reluctance of many of the coroner's physicians to perform an autopsy 
even in doubtful cases where the diagnosis cannot be accurately determined 
without such an examination, and their apparent willingness to accept the 




UlNE. OF FRACTURE. 



Fig. 91. — Small linear fracture of the squa- 
mous portion of left temporal bone in a patient 
who died three and one-half hours after the cra- 
nial injury from an acute medullary edema, due 
to an extreme intracranial pressure of cerebral 
edema alone. 



316 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

history as the most important factor of the cause of death in many of these 
patients is most discouraging to the staff of a hospital who are naturally 
more interested beyond the point of knowing that the patient died. The too 
common diagnosis of "fracture of the skull" is by no means a sufficient 
cause of death in itself, and it is this very diagnosis "fracture of the skull" 
that has retarded the development of the rational treatment of brain injuries 
possibly more than any other factor. There have been notable exceptions 
among the coroner's staff of physicians, particularly that of Doctor 0. H. 
Schultze, Doctor John McAllister and of Doctor Benjamin Schwartz, who 
are really interested in reaching the "real" diagnosis of the pathological 
condition in these patients and whose observations and suggestions have 
been most helpful to the attending physician and surgeon. 

Case 66. — Acute severe brain injury associated with high intra- 
cranial pressure due to cerebral edema. No operation. Medullary edema ; 
death. Autopsy. 

No. 299. — John. Fifty-seven years. White. Married. Laborer. Ireland. 

Admitted June 28, 1915, Polyclinic Hospital. 

Died July 1, 1915 — 61 hours after admission and 62 hours after injury. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — Patient is said to have fallen headforemost upon the 
street curbing while intoxicated; immediate loss of consciousness; brought 
to the hospital in the ambulance. 

Examination upon admission (55 minutes after injury). — Tempera- 
ture, 97.4° ; pulse, 90 ; respiration, 28 ; blood-pressure, 110. Profound un- 
consciousness and in a severe degree of shock. Strong odor of whiskey upon 
breath of patient. Profuse bleeding from nose and both ears, but an ecchy- 
mosis only over the left mastoid area. Both orbits ecchymosed with bilateral 
subconjunctival hemorrhages. Pupils — both dilated, left larger than right. 
Reflexes — patellar increased but equal ; no ankle clonus but double Babinski ; 
abdominal reflexes absent. Fundi negative. 

Treatment. — Expectant palliative ; vigorous anti-shock measures insti- 
tuted. The general condition of the patient improved so that 7 hours after 
admission the pulse had descended to 7-4, respirations to 22, while the blood- 
pressure had ascended to 126. This improved condition did not remain 
longer than one hour, when the temperature quickly arose to 104°, pulse 
to 122, respirations to 30, while the blood-pressure now descended to 108. 
The following examination was made at this time : 

Examination (8 hours after admission). — Temperature, 104.4°; pulse, 
126 ; respiration, 32 ; blood-pressure, 104. Profound unconsciousness and in 
apparent medullary collapse. Bleeding from both ears has ceased ; otoscopic 
examination reveals a laceration of posterior portion of left tympanic mem- 
brane ; although there is blood in the right auditory canal no lacera- 
tion of the right tympanic membrane is visible; left mastoid ecchymosis 
present but right mastoid area is negative. Pupils widely dilated and 
do not react to light. Reflexes all depressed but apparently equal ; double 
Babinski still persists. Fundi — retinal veins enlarged; nasal margins of 
both optic disks blurred by edema. Lumbar puncture — clear cerebrospinal 



ACUTE BRAIN INJURIES 



3i7 



fluid with an occasional streak of blood under high intracranial pressure 
(approximately 19 mm.). 

Treatment. — The condition of medullary edema had occurred so rapidly 
following the lessening of the shock that at no time were the signs of 
acute medullary compression to be ascertained clinically, and therefore no 
operative relief of the intracranial pressure could be offered in the hope 
of retarding the onset of an acute medullary edema. The patient was 
treated expectantly in the forlorn hope that the signs of medullary edema 
would disappear, but the general condition of the patient progres*sively 
became worse — temperature reaching 106.8°, pulse 146, respiration 42, while 
the blood-pressure descended to below 86 within 36 hours after admission, 
and the patient finally died 61 hours after admission. 

Autopsy (Doctor John McAllister). — Small linear fracture of 5 cm. 
long* in squamous portion of left temporal bone extending obliquely down- 
ward into mastoid and petrous por- 
tions (Fig. 92). No extra- nor sub- 
dural hemorrhage. Over anterior 
portion of left cerebral hemisphere 
was a very thin film of subarachnoid 
hemorrhage — in all not more than a 
teaspoonful. Brain itself very swollen 
and " water-logged " and no punctate 
hemorrhages or lacerations in it; 
medulla also boggy and "wet." Ven- 
tricles negative. Examination of 
heart, lungs, liver and kidneys was 
practically negative. 

Remarks. — This case is most inter- 
esting in that the coroner had great 
difficulty in ascertaining the cause of 
death — so much so that during the 

autopsy he frequently complained that a sufficient cause of death did not 
seem to be present since with the exception of a mild interstitial nephritis, 
hepatic fibrosis in addition to a slight valvular cardiac lesion, the finding's at 
autopsy were practically negative— unless the "wet" edematous swollen con- 
dition of the brain was the immediate cause of death by means of an acute 
medullary edema. This latter belief was undoubtedly the explanation for the 
death of this patient having a severe- head injury and upon admission to the 
hospital being in the condition of shock (temperature subnormal, pulse 90 
and a blood-pressure of only 110) ; as the shock lessened, the temperature 
ascended to 101°, the pulse descended to 74, while the blood-pressure in- 
creased to 126 — that is, the signs of an increased intracranial pressure over- 
shadowing those signs of shock. However, the resistance of the patient 
to any increase of the intracranial pressure was so impaired that these mild 
signs of medullary compression resulting irom the increased intracranial 
pressure quickly changed into the signs of acute medullary edema— the tem- 
perature rising rapidly to 104.4°, pulse to 126, while the blood-pressure 
descended quickly to 100 and lower. This patient did not die from shock. 




UNt OF FRACTWHt 



Fig. 92.— Small linear fracture of left vault 
and base in a patient precipitated early into 
the condition of acute medullary edema as the 
result of an extreme intracranial pressure due to 
cerebral edema. 



318 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

as a marked increased intracranial pressure is, in my opinion, impossible in 
the presence of extreme shock, and this patient did have a high intracranial 
pressure as accurately demonstrated by the lumbar puncture and, to a lesser 
degree, by the ophthalmoscopic examination of the fundi — a less accurate 
means of determining the intracranial pressure. 

The fracture of the skull opening into the left auditory canal offered 
a means of lessening the increased intracranial pressure by a sort of natural 
decompression ; in many patients, this natural drainage is sufficient to lower 
the intracranial pressure and thus an operation is avoided, but in the 
majority of patients the outlet for the escape of blood and cerebrospinal 
fluid through the fracture in the ear becomes blocked early, and thus a 
further lessening of the pressure is not possible. The danger of infection 
also through this channel must always be considered, and yet if no meddle- 
some cleaning of the external auditory canal is attempted and merely a 
sterile gauze pad applied loosely to the lobe of the ear, the risk of infection 
is really slight. 

B. Fracture not present. 

a. High intracranial pressure due to large hemorrhage. 

Case 67. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to large hemorrhage. No operation. Medullary edema ; 
death. Autopsy. 

No. 153. — Charles. Fifty-eight years. White. Married. Steamfitter. 
Germany. 

Admitted July 3, 1914, Polyclinic Hospital. Referred by Doctor 
R. E. Brennan. 

Died July 5, 1914 — 30 hours after admission and 30% hours after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While riding upon an automobile truck, patient was 
thrown to the street as the result of a collision ; momentary loss of conscious- 
ness ; brought to the hospital in the automobile. 

Examination upon admission (25 minutes after injury). — Tempera- 
ture, 99.4° ; pulse, 68 ; respiration, 20 ; blood-pressure, 130. Perfectly con- 
scious, although the patient does not recall the accident ; no alcoholism. 
Multiple lacerations and contusions of entire body. Fracture of right 
lower jaw. No bleeding from nose, mouth or ears; otoscopic examination 
negative. Pupils equal and react normally. Reflexes negative. Fundi — 
retinal veins enlarged ; nasal margins of both optic disks blurred. Lumbar 
puncture — very blood}^ cerebrospinal fluid under increased pressure (ap- 
proximately 16 mm.) ; upon allowing the cerebrospinal fluid to stand, almost 
50 per cent, of it was blood. 

Treatment. — Expectant palliative. The intracranial pressure did not 
seem to be sufficiently high enough to warrant an immediate operation of 
decompression and drainage — it was hoped that the patient could "take 
care of" this increased pressure and blood by the natural means of absorp- 
tion. Patient was frequently examined, and the general condition improved, 
although the pulse remained between 64 and 68 and the ophthalmoscopic 
examinations revealed an increasing intracranial pressure so that both optic 






ACUTE BRAIN INJURIES 319 

disks were entirely obscured by edema, but no measurable swelling of the 
disks — that is, a papilledema of mild degree ; at this examination 15 hours 
after admission, a lumbar puncture was performed, allowing bloody cerebro- 
spinal fluid to escape under high pressure (approximately 18 mm.). As 
there were no localizing signs, and as the reflexes still remained negative 
without a Babinski and as the general condition of the patient seemed so 
good in that he remained perfectly conscious and did not complain of severe 
headache, it was considered advisable to watch him carefully and i£ the 
signs of high intracranial pressure became more marked and his general 
condition became worse, then the operation of subtemporal decompression 
and drainage would be advised. (We now know that this attitude is noc 
conservatism but rather one of ignorance and that it would have been and is 
always a much safer procedure to perform the operation of subtemporal 
decompression and drainage early in the presence of the definite signs 
of increased intracranial pressure as recorded by the ophthalmoscope and 
the spinal mercurial manometer, and that it is not necessary to have profound 
unconsciousness, changes of reflexes, so-called "localizing" signs, a very slow 
pulse with Cheyne-Stokes respiration and a high blood-pressure in order 
that the operation of cranial decompression be advised; these latter signs 
frequently do not occur and very frequently when they do occur, they appear 
so late in the progress of medullary compression that a medullary edema is 
very easily precipitated.) 

Patient remained in practically the same excellent condition of conscious- 
ness with no definite complaints until the morning of July 5, at one 'clock, 
when he suddenly awakened from a heavy sleep, became very noisy and irra- 
tional, got out of bed, stood up, and upon being put into bed and restrained, 
he became comatose within 10 minutes, his pulse ascended to 148, while the 
blood-pressure dropped to below 90 ; ophthalmoscopic examination revealed 
dilated retinal veins with both optic disks blurred to the measurable swelling 
of 2 diopters — that is, the early stage of "choked disks." Respiration 
stopped 10 minutes later, and although artificial respiration was performed 
and the heart continued to beat for 6 minutes, yet the patient died — a 
death of typical medullary edema. 

Autopsy. — Small laceration of scalp over posterior occipital area. Xo 
fracture of the skull could be found. No extradural hemorrhage. Large 
subdural hemorrhage of dark syrupy character and about one-fourth inch in 
thickness over both cerebral hemispheres. No cortical hemorrhage nor 
laceration. Much free blood and cerebrospinal fluid subtentorially about 
the medulla. Ventricles negative. 

Remarks. — This patient naturally should have been operated upon — a 
subtemporal decompression and drainage used, and if necessary, a bilateral 
decompression, within 15 hours after admission, when the signs of an in- 
creased intracranial pressure appeared both in the fundi and at lumbar 
puncture, rather than waiting for unconsciousness and localizing signs or a 
very slow pulse, Cheyne-Stokes respiration and a high blood-pressure. To 
allow patients of this character to attempt "to take care of intracranial 
pressure of this severity is a most risky procedure — a far greater danger to 



320 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the patient than the operation of decompression performed under modern 
conditions of asepsis and technic. 

It is indeed surprising that the patient, in view of the autopsy findings, 
did not have more signs of cortical irritation and even of cortical com- 
pression ; not only were the reflexes not increased and no Babinski present, 
but the pupils were of normal size and of normal reaction to light, and the 
only sign of cortical irritation was possibly the extreme restlessness of 
the patient — although this was not more than is ordinarily observed in 
many patients. 

Three hours before death, an ophthalmoscopic examination had been 
made and the report of the house surgeon was that a papilledema of one 
diopter was present : undoubtedly the operation should have been performed 
at this late date, but it was still believed that the patient would recover 
without an operation — ''the general condition was so good, the pulse only 
66. and not even a Babinski." 

The absence of a fracture of the skull merely emphasizes the relative 
unimportance of the fracture in patients having brain injuries, unless it is 
remembered that the fracture frequently offers a means of escape for blood 
and cerebrospinal fluid, and thus a natural method of lessening an increased 
intracranial pressure is afforded so that an operation may be avoided ; the 
most severe cases, as this patient illustrates, are very frequently not even 
associated with a fracture of the skull, 

b. High intracranial pressure due to cerebral edema alone, and no intra- 
cranial hemorrhage present. 

C^se 68. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to cerebral edema alone. No operation. Medullary 
edema ; death. Autopsy. 

No. 965. — Unknown woman. About fifty years. White. 

Admitted March 14. 1918. Polyclinic Hospital. 

Died March 16, 1918 — ±2 hours after admission. 

Family history not known. 

Personal history not known. 

Present III tie ss. — AVhile crossing the street in an intoxicated condition, 
patient was knocked down by an automobile ; immediate loss of conscious- 
ness : brought to the hospital in the automobile. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture. 97.8 = ; pulse. 50: respiration, 24; blood-pressure, 112. Profound un- 
consciousness. vVell-nourished and rather obese plethoric woman of about 
50 years of age. Laceration of scalp over left frontal area of 4 inches in 
length : careful probing revealed no underlying fracture or depression. 
Bleeding profusely from left ear : extensive left mastoid ecchymosis. Pupils 
equally dilated and do not react to light. Reflexes — patellar exaggerated 
but apparently equal ; no ankle clonus nor Babinski ; abdominal reflexes 
absent. Fundi — retinal veins enlarged and a general haziness of entire 
retinae not limited to optic disks. Lumbar puncture — clear cerebrospinal 
fluid under normal pressure (8 mm.) . 

Treatment. — Expectant palliative; vigorous anti-shock measures insti- 
tuted. However, within 2 hours after admission the temperature had 



ACUTE BRAIN INJURIES 321 

ascended to 101°, while the pulse had risen rapidly to 126, respiration 
to 36, while the blood-pressure had decreased to 104. The general condition 
of the patient rapidly became worse so that 24 hours after admission the 
temperature was 105°, pulse 142, respiration 40 and the blood-pressure 92. 
Patient became markedly cyanotic and the signs of pulmonary edema 
developed, so that rattling- moist rales occurred throughout both lungs ; in 
spite of most active stimulative treatment, the condition of the patient 
became worse and she finally died 42 hours after admission from a 
typical medullary edema. 

Autopsy. — Multiple ecchymoses of the scalp, especially in the left mas- 
toid area ; no fracture of the skull ascertained. The cerebral hemispheres 
were very "wet" and "water-logged," but no gross subdural or intracere- 
bral hemorrhages found. Much clear cerebrospinal fluid subtentorially about 
the medulla. Anterior surface of right frontal lobe slightly contused with 
an occasional punctate hemorrhage in several places. Ventricles negative. 

Remarks. — Upon admission, the subnormal temperature and low blood- 
pressure indicated a high degree of shock ; and yet, if the ophthalmoscopic 
examination (which was practically negative, or at least did not show the 
signs of a high increased intracranial pressure) and the measurement of 
the pressure of the cerebrospinal fluid at lumbar puncture by means of the 
spinal mercurial manometer (which indicated an intracranial pressure of 
only 8 mm. ) had not been practically negative, it might have been believed 
that the general intracranial pressure was high and that it was the cause 
of the lowered pulse-rate of 50 in the presence of severe shock. I do not 
believe this was the case, but rather it was the condition of an acute direct 
medullary compression itself in a middle-aged woman having chronic 
alcoholism and that, as the subsequent history of the case show T s, this acute 
medullary compression changed very rapidly into the condition of acute 
medullary edema and therefore the early death of the patient. It would 
be most rare for a general intracranial pressure to produce an acute medul- 
lary compression sufficient to lower the pulse-rate to 50, and yet there 
not be these signs of a high intracranial pressure as revealed by the oph- 
thalmoscope, lumbar puncture and to a less accurate extent the blood-pres- 
sure itself. Besides it would be most difficult, and I doubt if it can happen, 
for extensive bleeding to occur intracranially — at least to an amount sufficient 
to increase the general intracranial pressure so that an acute medullary com- 
pression would occur — in the presence of shock to the extent of causing a 
subnormal temperature of 97.8° and a blood-pressure of only 112. 

A possible explanation that the lowered pulse-rate of 50 in this patient 
did indicate high intracranial pressure with a medullary compression, com- 
plicated clinically by the signs of severe shock, and that the lumbar punc- 
ture did not indicate an increased intracranial pressure because the cerebro- 
spinal fluid was blocked at the foramen magnum by the medullary compres- 
sion itself, is, in my opinion, not warranted, chiefly because the ophthalmo- 
scopic examination of both fundi was practically negative. 

I do not believe that this patient could have recovered under any cir- 
cumstances — operation or no operation — because the progress 0? the con- 
21 



322 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

dition with the onset of an acute medullary edema was so rapid that no 
treatment could be of any benefit. 

Acute Severe Brain Injuries Associated with a High Intracranial 
Pressure Due to Hemorrhage and Cerebral Edema. Subtemporal 
Decompression. Death; Autopsy. 

In this group of patients, with and without a fracture of the skull, the 
operation of subtemporal decompression was advised as the only known 
means of lowering the high intracranial pressure of hemorrhage and cerebral 
edema and thus affording the patient a chance of recovery ; without such an 
operation, almost all of these patients die or, if an exceptional patient should 
recover life under the expectant palliative treatment, then they practically 
never regain their former good health and normality — both physically and 
mentally, and also emotionally. The risk of the operation is slight com- 
pared with the gravity of the condition of these patients. When the signs 
of severe initial shock disappear, if it is determined that the intracranial 
pressure is increasing, as is best indicated by the ophthalmoscopic and spinal 
manometric tests as well as by the gradual descent of the pulse- and respira- 
tion-rates and the ascent of the blood-pressure, then the condition of the 
patient should be most carefully and repeatedly observed in the hope that 
the expectant palliative treatment alone will suffice to prevent a high intra- 
cranial pressure ;. but if it is ascertained that the intracranial pressure 
continues to rise beyond the limits adequately treated by the expectant pallia- 
tive method — such as an increased intracranial pressure sufficient to produce 
a papilledema or even an edematous blurring of the nasal halves and tem- 
poral margins of the optic disks and the pressure of the cerebrospinal fluid 
at lumbar puncture registers a height of 16 mm. and over, and especially 
if the pulse- and respiration-rates are 60 and 16 and lower, respectively, 
then there should be no delay in advising an immediate subtemporal decom- 
pression and drainage, and if at this operation the increased intracranial 
pressure is so high that the bulging cortex does not pulsate or only slightly 
so and comparatively little hemorrhage and cerebrospinal fluid are drained 
owing to the ' ' water-logged ' ' swollen condition of the brain, then an imme- 
diate bilateral decompression should be advised and performed. 

The high mortality in these patients is due not only to the extreme intra- 
cranial condition but also, and chiefly, to a delayed lowering of the increased 
intracranial pressure so that the patient is in a most hazardous condition 
of severe medullary compression before the operation is attempted; to 
allow these patients to develop definite signs of medullary compression 
with very low pulse- and respiration-rates of even 50 and 14 and lower, re- 
spectively, and of the Cheyne-Stokes character of rhythmical irregularity — 
when the onset of an acute medullary edema may occur at any moment and 
therefore the end of the patient within a few hours — in the hope and the 
belief that the patient can still "take care of" the condition, this attitude 
is a most mistaken one and cannot be too strongly condemned; no doubt 
there are patients, and we have had them in this series of cases, who do 
recover life from this extreme and dangerous condition of severe medullary 
compression with the expectant palliative treatment alone, but careful 
records show that the percentage of recovery of life alone is less than 4 per 



ACUTE BRAIN INJURIES 323 

cent., whereas with an early mechanical relief of this high intracranial 
pressure the patients are afforded a percentage of recovery of both life 
and future normality of almost 50 per cent. Naturally, the earlier the opera- 
tion of decompression is performed before the resistance of the patient is 
lowered to such an extent that the cardiac and respiratory centres in the 
medulla are exhausted — just so much more are the chances of recovery of 
the patient. It must be remembered in these emergency cases that it fre- 
quently happens, even after the operation has been decided upon, thal^the 
condition of the patient becomes rapidly so much worse that by the time 
all preparations for the' operation are made — at least one hour later — then 
the operation will be of no benefit to the patient and it should not be per- 
formed owing to the appearance of the signs of acute medullary edema ; the 
operation now would only hasten the exitus of the patient. In the present 
series of patients, this unfortunate complication occurred a number of times, 
and it is most discouraging ; the operating room and staff should be in readi- 
ness and prepared for immediate operations upon these patients who exhibit 
the early signs of medullary compression. 

Acute severe brain injuries, with and without a fracture of the skull, 
associated with high intracranial pressure due to intracranial hemorrhage 
and cerebral edema. Subtemporal decompression. Death. Autopsy. 

A. Unilateral subtemporal decompression. 

Case 69. — Acute severe brain injury having signs of high intracranial 
pressure due to extradural and subdural hemorrhage. Right subtemporal 
decompression and drainage. Death. Autopsy. 

No. 080. — Peter. Twenty-nine years. White. Single. Butler. U. S. 

Admitted November 1, 1913, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operation November 3, 1913 — 49 hours after injury. Right subtem- 
poral decompression and drainage. 

Died November 4, 1913 — 24 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was found lying on the sidewalk ; unconscious ; 
brought to the hospital in the ambulance. 

Examination upon admission (1 hour after injury). — Temperature, 
97°; pulse, 50; respiration, 16; blood-pressure, 140. Semiconscious with a 
strong odor of alcohol upon the breath, giving the impression of one intoxi- 
cated. Marked ecchymosis of right orbit. No bleeding from nose, mouth or 
ears ; left mastoid ecchymosis. Pupils slightly enlarged but equal ; reaction to 
light sluggish. Reflexes — patellar could not be elicited ; no ankle clonus 
nor Babinski ; abdominal reflexes absent. Fundi — retinal veins enlarged ; 
both optic disks clear. 

Treatment. — Expectant palliative; the lowered temperature, combined 
with the lowered pulse-rate, would indicate a combination of shock and 
intracranial pressure ; a lumbar puncture would have been very instructive 
as a more accurate means of determining the intracranial pressure, whether 
due to blood or edema; the ophthalmoscopical examination, however, being 
practically negative, made the expectant palliative treatment advisable in 
the hope that no operation would be necessary. Patient neither improved 



324 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

nor became worse in the next 2 days, but then the condition changed markedly 
as shown by the following examination : 

Examination (44 honrs after admission) . — Temperature, 102° ; pulse, 68 ; 
respiration 20; blood-pressure, 130. Patient still semiconscious — easily 
aroused but will not speak. Large occipital hematoma. Pupils equal and re- 
act normally. Reflexes : patellar — left greater than right ; no ankle clonus 
nor Babinski; abdominal reflexes both depressed but equal. Fundi — 
retinal veins dilated; nasal halves of both optic disks blurred. Lumbar 
puncture — bloody cerebrospinal fluid under high pressure (approxi- 
mately 18 mm.). 

Treatment. — Right subtemporal decompression and drainage advised 
immediately to lessen the increasing intracranial pressure. 

Operation (48 hours after admission). — Right subtemporal decompres- 
sion : usual vertical incision, 
bone removed and no compli- 
cations. Dura very tense and 
extending clown over the up- 

Jper third of the operative 
field was an extradural hem- 
orrhage, one-quarter inch in 
4 thickness ; this clot extended 
H| upward beneath the parietal 
bone. Upon incising the 
" % - dura, bloody cerebrospinal 
fluid spurted and upon 
enlarging the dural opening 
a very ' ' wet ' ' edematous cor- 
tex tended to protrude under 
I pressure, but did not rup- 
L- HIIIHII _ Jjk ture; arachnoid "sweating" 

Fig. 93.— Wide linear fracture of the "bursting" type of the WaS Very profuse. On aC- 
right half of the occipital bone in a patient having a high intra- , _p + v "U ' Vi "K 1 

cranial pressure, due to extradural and subdural hemorrhage. COUnt 01 tne UlgU Cerebral 

Slla^Sf decompression and drainage. Death from tensi(m> & ventricular P UUC- 

ture was performed, but 
clear cerebrospinal fluid under normal pressure escaped. In spite of the loss 
of a large quantity of cerebrospinal fluid and free blood, yet the cerebral 
tension remained quite high and only slight cerebral pulsation was visible. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 50 minutes. 

Post -operative Notes. — Patient did not become conscious after operation ; 
and he became weaker and weaker. Ten hours after operation the tempera- 
ture was 102.4°, pulse 130, respiration 44, and the blood-pressure 115 — that 
is, medullary edema had occurred, and naturally the death of the patient — 
24 hours after operation. X-ray (obtained post-mortem by Doctor A. J. 
Quimby) — "reveals a wide linear fracture extending from the occipital pro- 
tuberance into the right mastoid area; also right decompression is shown 
faintly" (Fig. 93). 

Autopsy. — Large hematoma 2 inches in diameter beneath the periosteum 
over right occipital bone ; several small hematomata in right frontal region. 



! 



ACUTE BRAIN INJURIES 



325 



Fracture extended around the head horizontally from the occipital protuber- 
ance into right mastoid area and also to the left to a point one-half inch above 
the left external auditory meatus ; this fracture was of the typical "bursting" 
type, being of special interest in that the line of fracture of the outer table was 
always very prominent and wider than the internal line of fracture which was 
even absent in several places (Fig. 94) , Several small lines of fracture radi- 
ated from this main horizontal fracture. Left frontal lobe and upper part of 
left temporo-sphenoidal lobe lacerated over an area of 2 inches in diameter.* 
Subdural hemorrhage over left frontal lobe. No cortical hemorrhage nor 
laceration over right side of brain. Ventricles normal ; no basal hemorrhage. 
The entire brain, however, was very much swollen with edema, "water- 
logged," and it was this edema with its resulting pressure which caused 
the death of the patient through 
medullary compression and the sub- 
sequent medullary edema. 

Remarks. — An earlier relief of 
the intracranial pressure might have 
afforded this patient a chance of re- 
covery; the alcoholism so masked the 
true intracranial condition that the 
symptoms and signs of intracranial 
pressure were not observed as having 
developed until 44 hours after admis- 
sion ; by this time the signs of medul- 
lary edema were already present — 
that is, the pulse was rising rapidly 
from 50 to 68, the respirations from 
16 to 20, and the blood-pressure was 
falling from 140 to 130; within 10 
hours after operation, the condition 
of medullary edema had so far advanced that the pulse had ascended to 
130, respiration to 44 and the blood-pressure had fallen to 115. That is. 
this patient, instead of being operated upon earlier in the stage of medullary 
compression in its milder form, had been allowed to advance so that 
the pulse had reached its lowest level before the signs of high intra- 
cranial pressure had been determined, and when they had been ascer- 
tained, then an operation had been advised when the signs of medullary 
edema were present; these patients almost invariably die once they have 
developed the definite signs of medullary edema, and*so it happened in this 
patient — operation or no operation. The mistake made in treating this 
patient was due to the observation that there was the odor of alcohol upon 
his breath, and therefore he was considered an alcoholic with a bump on 
his head rather than a patient with a possible brain injury having the odor 
of alcohol upon his breath; alcoholic intoxication does tend to mask the 
symptoms and signs of an acute brain injury, but if the signs of intracranial 
pressure, as ascertained by the ophthalmoscopic examination of the fundi 
and in the measurement of the cerebrospinal fluid at lumbar puncture by 
means of the spinal mercurial manometer are present, then those patients 




Fig. 94.— The left portion of the horizontal 
linear fracture of the posterior half of the vault. 
The line of fracture was characteristic of the 
"bursting" type of fracture in that the outer 
table was more widely separated than the inner 
table and frequently the inner table was not even 
fractured at all although the overlying table was 
definitely separated. 



326 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

should be treated accordingly, whether alcoholism is a factor or not. This 
patient, however, did not show signs of an increased intracranial pressure 
by the ophthalmoscopic examination, and therefore no lumbar puncture 
was performed upon admission — the condition being considered one rather 
of intoxication than of brain injury ; it is now realized that it is rare for 
the signs of increased intracranial pressure to be registered in the fundus 
of the eye within six hours after the injury, and therefore in all doubtful 
patients, the lumbar puncture is a most valuable and accurate means of 
determining the exact increase of the intracranial pressure, and it should 
always be performed in the absence of shock. 

These "bursting" fractures of the vault are interesting in that fre- 
quently, as Doctor 0. H. Schultze has mentioned, it is easily observable 
at autopsies that the middle portion of the "bursting" line of fracture or 
"crack" is much wider than either of the end portions, showing that the 
fracture is really the mechanical result of approximating the pole of contact 
and its opposite pole, so that it "bursts" or "cracks" in its thinnest or 
weakest meridian ; it was true in this patient. 

Case 70. — Acute severe brain injury associated with high intracranial 
pressure due to cerebral edema and subdural hemorrhage. Right subtem- 
poral decompression and drainage. Death. Autopsy. 

No. 852. — Arthur. Twenty-eight years. White. Married. Jockey. U. S. 

Admitted May 4, 1917 — 2 hours after injury. Coney Island Hospital, 
Coney Island, New York. Referred by Doctor L. T. Smith. 

Operation May 6, 1917 — 51 hours after admission. Right subtemporal 
decompression and drainage. 

Died May 7, 1917 — 30 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While driving an automobile, the patient collided with 
another car and was thrown headlong to the street ; immediate loss of con- 
sciousness; brought to the hospital in the ambulance; upon admission the 
pulse was 52 and there was profuse bleeding from both ears and profound 
unconsciousness ; an immediate operation was advised and a small trephine 
opening was made 5 hours after admission over the right parietal area, but 
the dura was not opened — merely a hypodermic needle inserted and a small, 
amount of bloody cerebrospinal fluid removed. At the end of the operation 
the pulse was 64, and 3 hours later it was 70, and within 10 hours after 
admission the pulse had rapidly risen to 128, where it remained during the 
next 6 hours, and then descended and varied from 112-124 until the 
following examination : 

Examination (48 hours after admission; in consultation with Doctor 
Smith). — Temperature, 100.8°; pulse, 112; respiration, 28; blood-pressure, 
126. Profound unconsciousness. Right eye extensively ecchymosed and 
much clotted blood in both auditory canals, and there is still a slight bloody 
discharge from right ear; boggy bilateral mastoid ecchymosis. Pupils — 
right larger than left and reacts to light sluggishly. Reflexes: patellar — 
left greater than right ; double ankle clonus and double Babinski ; abdom- 
inal reflexes absent. Fundi — retinal veins dilated, blurred and tortuous; 



ACUTE BRAIN INJURIES 327 

both nasal and temporal halves of optic disks obscured by edema but no 
measurable swelling* to the extent of one diopter. Lumbar puncture — 
bloody cerebrospinal fluid under high intracranial pressure (approximately 
17 mm.). 

Treatment. — It was a most difficult question to decide whether a sub- 
temporal decompression should be advised at this late period or whether 
the condition should be considered hopeless and no operation considered; 
yet at the time, I considered it a borderline case from the operative stand- 
point and I felt that an operation might give the patient a definite chance to 
recover (and in this opinion I was mistaken). An immediate right sub- 
temporal decompression w T as advised in the hope that a lessening of the 
intracranial pressure would permit the signs of medullary edema to subside 
and thus the recovery of the patient be obtained. 

Operation (51 hours after admission). — Right subtemporal decompres- 
sion (no anesthesia being necessary) : usual vertical incision, bone removed 
and no complications ; lower branch of right middle meningeal artery bled 
freely until successfully blocked with bone wax. Dura very tense and bluish, 
and upon incising it, dark bloody cerebrospinal fluid spurted to a height of 
2 inches; upon enlarging dural opening, much bloody cerebrospinal fluid 
w T elled out through opening, revealing a very ' ' wet, ' ' congested, swollen brain 
which began to pulsate after the escape of much cerebrospinal fluid and 
free blood (it was observed at this time that the patient became less 
resistant and quieter, breathed less irregularly and not so stertorously, and 
also the pulse became better in quality but did not become less rapid). 
No cortical hemorrhage or laceration visible. Usual closure with 2 drains 
of rubber tissue inserted. Duration, 50 minutes. 

Post-operative Notes. — Patient remained in practically the same condi- 
tion as immediately before the operation, except that the general condition 
seemed improved; did not become conscious, however, and neither did the 
pulse nor respiration descend, although their character was improved ; after 
24 hours, however, the patient rapidly became worse — temperature ascended 
to 107°, pulse and respiration rose quickly to 150 and 38, respectively, and 
the patient died 30 hours after operation and 78 hours after injury from 
the typical condition of medullary edema and collapse. 

Autopsy. — Fracture of base through both middle fossae and both petrous 
portions of temporal bones; no fracture of vault ascertained (Fig. 95). No 
extradural hemorrhage and only a thin film of subdural hemorrhage mixed 
with cerebrospinal fluid. Anterior portion of right frontal lobe con- 
tused but not extensively. Brain itself very edematous and much cerebro- 
spinal fluid subdurally. No cortical punctate hemorrhages or lacera- 
tions ascertained. 

Remarks. — This patient would have had an excellent chance to recover 
if a subtemporal decompression had been performed immediately after the 
patient's admission to the hospital, when the pulse was 52 — that is. pre- 
sumably the stage of medullary compression as indicated by a very low 
pulse-rate. The operation which was performed at that time— a small tre- 
phine opening and the dura not opened, and particularly the use of a 
hypodermic needle thrust "blindly" through the dura — can hardly be 



328 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



considered an operation unless classed as meddlesome surgery with great 
danger to the patient ; to remove an area of bone and not to open the dnra 
widely does not permit a cranial decompression to occur, as the dura is 
inelastic in adults and the entire top of a patient's head — that is, the bony 
vault — could be rongeured away and yet, if the dura was not widely opened, 
no decompression or relief of the intradural pressure would be possible. 
The use of a hypodermic needle to ascertain the presence or not of subdural 
blood is not only distinctly dangerous but it can be of no aid in the treat- 
ment; it is not the presence of subdural blood which is necessary to be 
ascertained in the operative treatment or not but the presence or not of 
an increased intracranial pressure ; beside the accurate tests preceding any 
cranial operation for estimating approximately the intracranial pressure — 
such as careful ophthalmoscopic examinations and the measurement of the 

pressure of the cerebrospinal fluid at 
lumbar puncture by means of the 
spinal mercurial manometer, and if 
an operation is considered advisable, 
then upon exposing the dura through 
a large bony opening it is very easily 
ascertained by palpation of the dura, 
whether the intradural pressure is 
high or not, and the appropriate pro- 
cedure can then be performed. A 
small trephine opening, and particu- 
larly over the parietal area, is dis- 
tinctly dangerous and unsurgical — if 
the dura is not opened then the opera- 
tion itself is not warranted because 
no benefit can possibly result from 
such a procedure, and if the dura is 
opened and the intradural pressure is 
high, then there is the great danger 
of the underlying cerebral motor cor- 
tex being forced upward through the small dural and bony opening and thus 
producing a permanent damage to these nerve cells and resulting in paral- 
ysis, impairments of sensation, special senses and of speech itself; the 
danger also of post-traumatic sequelae from such damage to the cerebral cor- 
tex must always be remembered. In a general way, in the presence of high 
intracranial pressure, a small bony opening of the vault (and the dura 
opened) is always much more dangerous and liable to complications than 
a large bony opening; many disasters in cranial surgery in the presence of 
high intracranial pressure have been, and are due to, a small and supposedly 
"safe" opening of the bony vault. 

The operation of cranial decompression performed upon this patient 
occurred at too late a stage to prevent the usual progress of medullary 
edema — once it has begun ; it is rare for a patient to recover once the pulse 
has descended to its lowest level of medullary compression and then when 
the pulse begins to rise rapidly and the blood-pressure to fall, indicating 




Fig. 95. — Extensive basilar fracture through 
both petrous bones and the sella turcica in a 
patient having a high intracranial pressure due 
to a subdural hemorrhage and cerebral edema. 
A right subtemporal decompression and drainage 
failed to prevent the progress of an advancing 
medullary edema and the death of the patient. 



ACUTE BRAIN INJURIES 329 

the onset of medullary edema, then it is exceedingly rare for the patient to 
recover — operation or no operation. In this patient, however, although the 
pulse had ascended within 10 hours from 52 to 128 (the respiration corre- 
spondingly, and the blood-pressure had descended), yet the pulse then de- 
scended slightly and remained between 112-124, until 38 hours later, when 
the consultation was held ; it appeared that the patient was withstanding the 
effects of the medullary edema, at least temporarily, and it was hoped that 
the patient would have a greater chance of recovery if the intracranial 
pressure was lessened by a subtemporal decompression and drainage of the 
bloody cerebrospinal fluid. It was considered that the patient without an 
operation had no chance to recover from the medullary edema and that he 
might have a definite chance if the operation of cranial decompression was 
performed. My experience with similar patients does not confirm this 
belief, and I do not think that a cranial operation is justified in these 
patients who have passed through the stage of medullary compression and 
have advanced into the period of medullary edema where the pulse-rate is 
above 110 and the blood-pressure is below 120; it is indeed very difficult 
to refuse to operate upon these patients in the early stage of medullary 
edema — hoping* against hope that the operation may give them a chance 
of recovery, but these patients recover so rarely that the operation is hardly 
justified and it is not creditable to modern surgery to advise cranial opera- 
tions upon these patients in this condition of severe medullary edema. 

The profuse discharge of blood through both ears undoubtedly lessened 
the increased intracranial pressure and delayed the onset of medullary 
edema; it is unfortunate that this drainage usually ceases within 12 hours 
after the injury, and although the danger of infection through the ear 
increases if the drainage is prolonged beyond 48 hours, yet the risk of 
such a complication is ordinarily a slight one if meddlesome treatment of 
blocking or irrigating the ear is not used. 

Case 71. — Acute severe brain injury with subdural hemorrhage asso- 
ciated with a marked degree of shock and medullary edema. Right sub- 
temporal decompression and drainage. Death. Autopsy. 

No. 051. — Daniel. Forty-one years. White. Married. Longshore- 
man. Ireland. 

Admitted October 21, 1913, Polyclinic Hospital. Referred by John 
A. Bodine. 

Operation October 22, 1913 — 25 hours after injury. Right subtem- 
poral decompression and drainage. 

Died October 23, 1913 — 18 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — "While intoxicated, patient was struck by a street car ; 
immediate loss of consciousness; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury), — Tempera- 
ture, 98°; pulse, 120; respiration, 28; blood-pressure. 120. Rather obese 
and well-nourished ; alcoholic. Profound unconsciousness ; severe degree 
of shock. Extensive laceration over external occipital protuberance; gentle 
probing did not reveal an underlying fracture. Profuse bleeding from right 



330 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

ear; no cerebrospinal fluid observed. Pupils — right larger than left and 
does not react to light. Eeflexes — patellar present and equal; no ankle 
clonus nor Babinski ; abdominal reflexes cannot be obtained. Fundi negative. 

Treatment. — Expectant palliative; vigorous anti-shock measures insti- 
tuted. During the next 12 hours, patient's condition improved apparently 
so that he became semiconscious and could be easily aroused, but not suffi- 
ciently to answer questions; marked ecchymosis of right eye. Fourteen 
hours after admission, patient had a convulsive seizure of left side of face 
and left arm, but left leg not involved ; at this time, temperature was 101.4° , 
pulse 134, respiration 34, blood-pressure 120 ; reflexes and fundi same as at 
preceding examination. Sixteen hours after admission, temperature was 
103.4°, pulse 140, respiration 40, blood-pressure 110, and patient had an- 
other convulsion limited to left side of face, left arm, and left leg, and lasting 
3 minutes. Fundi — retinal veins dilated ; nasal margins of both optic disks 
blurred by edema. Nineteen hours after admission, another convulsion 
occurred limited to left side of body, and then similar convulsions occurred 
every 15 minutes until 22 hours after admission, when they were finally 
checked by the use of chloroform, morphia, bromides and chloral per rectum ; 
at this time, patient was in extremis so that atropine, cupping, intravenous 
saline injections and extensive stimulation were used to prevent the appear- 
ance of a pulmonary edema and to raise the blood-pressure which had 
descended to a 104. Through a mistaken conception that the patient might 
be given a chance to recover if a subtemporal decompression was performed, 
even in this advanced stage of medullary edema and although there were 
no signs of pressure to be observed either by an ophthalmoscopic examina- 
tion of the fundi or by lumbar puncture, yet the operation was advised. 
("We now know that any cranial operation performed during the period of 
initial and severe shock following head injuries or during the period of 
medullary edema, and especially during the more advanced stages of 
medullary edema, that any cranial operation during these two periods tends 
to take away whatever chances the patient has to recover, and although 
without an operation a patient in medullary edema has little or no chance 
of recovery, yet if an operation is performed during this period the death of 
the patient is merely hastened.) 

Operation (24 hours after admission). — Right subtemporal decompres- 
sion : usual vertical incision, removal of bone and no complications. Dura 
moderately tense and bluish, and upon incising it blood-tinged cerebro- 
spinal fluid welled out through the dural opening, revealing a very "wet," 
edematous cortex, but not under sufficiently high tension to cause it to 
protrude ; many subdural clots. Ventricular puncture removed almost 
three ounces of blood-tinged cerebrospinal fluid, but not under high pressure. 
Much cerebrospinal fluid escaped and the cortex pulsated rapidly and feebly 
at end of operation — the patient being in poor condition. Usual closure with 
2 drains of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — Patient did not react after the operation but 
became gradually worse, so that 12 hours after operation the temperature 
was 106°, pulse 160, respiration 34, blood-pressure 90; patient died 18 hours 
after operation from the condition of typical medullary edema and collapse. 



ACUTE BRAIN INJURIES 



33i 



Autopsy. — Line of fracture radiated from external occipital protuber- 
ance downward in median line across the foramen magnum and upward 
through basilar process anteriorly to the posterior clinoid process of the 
sella turcica (Fig. 96). Ecchymosis of both orbits and bilateral subcon- 
junctival hemorrhages ; between the orbital periosteum and bone there were 
several small hemorrhages in both orbits — more in right than in left, and 
this accounted for the bilateral subconjunctival hemorrhages and orbital 
ecchymoses; there was, however, no fracture of the orbital bones themselves. 
Clotted blood in the right external auditory canal with a laceration of the 
right tympanic membrane and clotted blood in the right middle ear and yet 
no fracture of the petrous bone, although there was a small clot above the 
tegmen tympani. No extradural hemorrhage ; bloody subdural cerebrospinal 
fluid with extensive laceration and supracortical hemorrhage of botii 
frontal lobes, particularly the left 
(Fig. 97). Much hemorrhage and 
subdural clots subtentorially about 
the cerebellum, and especially over 
the posterior surface of the medulla. 

Remarks. — This case clearly illus- 
trates the futility of operating upon 
patients who have progressed into 
the stage of medullary edema and 
these patients should never be oper- 
ated upon in the mistaken belief that 
the operation may give the patient a 
chance to recover. Operations per- 
formed in this stage of medullary 
edema and also in the stage of severe 
shock immediately following so many 
cranial injuries tend to discredit 
cranial surgery as the mortality is 
very high, and in the condition of 
extreme shock a cranial operation 

tends to lessen the patient's chance ofl overcoming the shock and thus in 
reality takes away to a large extent the patient's chance of surviving 
the shock. 

This case also illustrates the great danger of fractures of the skull 
occurring beneath the tentorium; any cranial injury sufficient to cause a 
fracture beneath the tentorium is most liable to cause a definite brain injury 
subtentorially, either directly or by hemorrhage and edema, and thus increas- 
ing the subtentorial pressure and consequently a direct medullary com- 
pression with the great danger of an early medullary edema and collapse: 
the medullary edema may occur so rapidly after the disappearance of the 
signs of shock that the condition of shock may merge directly into that of 
medullary edema without apparently progressing through the condition of 
medullary compression — at least clinically; and so it happened in this 
patient — upon admission the condition was one of shock with a temperature 
of 98° and a pnlse of 120; during the next 12 hours the patient recovered 




Fig. 96. — Wide linear fractures of the occip- 
ital bone and extending into the foramen mag- 
num — the most dangerous type of cranial fracture 
on account of the frequent subtentorial complica- 
tion of direct medullary compression and the 
resulting edema — as occurred in this patient. 



332 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



somewhat from the condition of shock only to pass into the stage of meclul 
lary edema with a temperature of 101° and a pnlse of 134, and then the 
usual history of medullary edema — the temperature rising rapidly, the pulse- 
and respiration-rates also ascending, while the blood-pressure descends. 
At no time during the examinations of this patient could the signs of high 
intracranial pressure be ascertained and thus from this standpoint again 
no operation was indicated — no matter how badly the skull might be frac- 
tured — if there was no increased intracranial pressure, the operation could 
surely not be a decompression and therefore there could be no logical reason 
why an operation should be performed. Undoubtedly, the patient could not 
bleed intracranially to any extent on account of the lowered blood-pressure 

of shock, and then what- 
ever subtentorial bleed- 
ing occurred exerted 
such high and rapidly- 
forming direct pressure 
upon the medulla that 
medullary edema was 
produced unusually 
early — as so frequently 
happens in cases of sub- 
tentorial fractures of 
the skull or rather acute 
subtentorial lesions pro- 
ducing a rapid increase 
of the subtentorial pres- 
sure. In a small per- 
centage of patients 
having increased sub- 
tentorial pressure associ- 
ated with or without 
an occipital fracture in 
cases of cranial injury, 
the suboccipital decom- 
pression may be indicated when the signs of medullary compression are 
present, due more to the local condition of increased subtentorial pressure 
than to a high increase of the general intracranial pressure — in which latter 
patients the subtemporal decompression is always to be preferred. It is rare, 
however, in acute brain injuries for a simple medullary compression due 
to direct subtentorial pressure to occur and to remain uncomplicated by a 
medullary edema for a sufficiently long time to permit a suboccipital decom- 
pression to be performed; not only is the suboccipital decompression a 
much more formidable operation than the subtemporal decompression, but 
in these acute subtentorial lesions, medullary edema occurs so quickly that 
the patient is really moribund before he can be prepared for an opera- 
tion — let alone the performance of the operation itself; in chronic 
lesions subtentorially, the increase of subtentorial pressure is so gradual, 
as in cerebellar and in cerebello-pontine angle tumors, that the signs of 



. 




Fig. 97. — Extensive supraeortieal and subarachnoid hemorrhages 
of both cerebral hemispheres, left possibly more than right. Both 
frontal lobes lacerated, especially upon their inferior surfaces. 



ACUTE BRAIN INJURIES 333 

medullary compression may persist for a number of weeks before the 
terminal stage of medullary edema is induced. 

The post-mortem findings of small hemorrhages between the periosteum 
and the bone in the posterior portion of both orbital fossae, and yet no frac- 
ture of the orbital bones themselves being present, confirm the opinion that 
subconjunctival hemorrhages and naturally orbital ecchymoses do not neces- 
sarily indicate a fracture of any of the orbital bones ; also, the finding of a 
clot above the right tegmen tympani with no fracture of the petrous portion 
of the right temporal bone and yet the profuse discharge of blood from the 
right external auditory canal with a laceration of the right tympanic mem- 
brane and clotted blood in the right middle ear — this observation would 
tend to indicate that a fracture of the petrous portion of the temporal bone 
was not necessarily present when a laceration of the drum of the ear occurs 
with a profuse discharge of blood ; naturally, the presence of cerebrospinal 
fluid in the external auditory canal would imply a fracture of the temporal 
bone, but if only blood is observed and it is not mixed with cerebrospinal 
fluid, then it can only be said when the tympanic membrane is also ruptured 
that there is most probably a fracture of the temporal bone but not with 
absolute certainty. I feel, however, that it is rare for the condition to occur, 
as observed in this patient, without a fracture of the temporal bone being 
present, but it should always be remembered. 

It was absurd to have advised a cranial operation upon this patient — the 
severe condition of medullary edema having been permitted to develop. In 
these later days, no operation would ever be advised during this stage of 
extreme medullary edema where the pulse- and respiration-rates were 
rapidly ascending, even though the signs of high intracranial pressure are 
present; if the patient cannot survive this condition of medullary edema 
(and he only can in the most exceptional cases) , then surely no operation will 
help him as it seems the condition of medullary edema is always increased 
by the loss of blood at the operation and the exitus of the patient is really 
hastened. It is rather surprising that the condition of medullary edema 
should have occurred so quickly after the injury and merely indicates both 
the severity of the intracranial pressure and the lessened resistance of the 
patient to this increased pressure. It was not the condition of shock which 
is almost always associated with cranial injuries, for the following reasons : 
the high temperature, the; increasing pulse-rate, which was only 90 in the 
ambulance, and the signs of high intracranial pressure which would not have 
been present if the initial shock had been severe, since the blood-pressure 
then would have been so lowered that a large intracranial hemorrhage could 
not have occurred, because the increased intracranial pressure would have 
quickly equalled the lowered blood-pressure of shock, and therefore all 
intracranial bleeding would have quickly ceased until the shock had subsided. 

The extensive laceration of the frontal lobes — the left being greater than 
the right — illustrates the " trauma au coutrc-coup" — the point of contact 
being in the right occipital area. 

No lumbar puncture should be performed upon these patients in the 
presence of signs of high intracranial pressure in the fundi as revealed 
by the ophthalmoscope — a measurable papilledema of over 2 diopters and 



334 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

thus designated as the condition of "" choked disks." A lumbar puncture 
would merely reveal the presence or not of blood in the spinal cerebrospinal 
fluid and that information is of no importance in the treatment — the pres- 
ence or not of a high increase of the intracranial pressure being the all- 
important factor in the method of treatment, whether the expectant pallia- 
tive or the operative treatment being advisable. 

The ventricle puncture revealing the presence of a ventricular hemor- 
rhage made the prognosis of this patient a most serious one, as this com- 
plication usually causes a fatal termination early. 

Case 72. — Acute severe brain injury having marked signs of high intra- 
cranial pressure due to subdural hemorrhage and cerebral edema. Left 
subtemporal decompression and drainage. Death. Autopsy. 

No. 670. — James. Twenty years. "White. Single. Chauffeur. U. S. 

Admitted August 29. 1916. Polyclinic Hospital. 

Operation August 29. 1916 — KUo hours after injury. Left subtem- 
poral decompression and drainage. 

Died August 30. 1916 — 21 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While driving his automobile, patient collided with 
another car and was hurled headlong to the street; immediate loss of 
consciousness: brought to the hospital in the automobile. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture. 98° ; pulse. 92; respiration, 28; blood-pressure. 118. Unconscious and 
in shock. Stellate laceration over left portion of occipital protuberance ; 
careful probing revealed no underlying fracture. Small amount of blood 
trickled from left ear and nose. Pupils — enlarged and react sluggishly to 
light. Reflexes — negative except that they were all depressed. Owing to 
the shock no further examination was made at this time. 

Treatment. — Expectant palliative; vigorous anti-shock measures 
instituted. 

Examination (8 hours after admission). — Temperature, 104°; pulse, 
74: respiration. 18: blood-pressure. 138. Patient still unconscious but has 
become very restless, requiring restraint. Still bleeding slightly from left 
ear. Pupils — right larger than left and does not react to light. Reflexes : 
patellar — right greater than left; no ankle clonus but suggestive right 
Babinski ; abdominal reflexes — right absent and the left are very sluggish. 
Fundi — retinal veins dilated: both optic disks entirely obscured by edema 
with a measurable swelling of 1-2 dio]3ters — that is. the condition of papille- 
dema but not to the degree of "choked disks." Lumbar puncture — bloody 
cerebrospinal fluid under high pressure (approximately 18 mm.). 

Treatment. — On account of the early rise of the intracranial pressure 
so that the condition of shock was entirely overshadowed by the signs of 
intracranial pressure, a subtemporal decompression was advised for fear 
that an early medullary edema would occur : the presence of a suggestive 
right Babinski with increased right deep reflexes and diminished right 
superficial reflexes made a left subtemporal decompression advisable, 
although the dilated right pupil would tend to make a right subtemporal 



■; 



ACUTE BRAIN INJURIES 335 

decompression to be preferred — as it always is in right-handed patients and 
where the localizing signs are not definite or are even confusing. 

Operation (10 hours after admission) . — Left subtemporal decompression : 
usual vertical incision, bone removed and no complications. Dura very 
tense and bluish, and upon incising it, bloody cerebrospinal fluid welled out 
under very high pressure ; upon enlarging the dural opening, there was ex- 
posed a supracortical layer of blood-clot of one-quarter inch in thickness. 
The cerebral tension was so high that the hernial protrusion caused a cortical 
rupture just beneath the Sylvian fissure ; however, so much free blood and 
cerebrospinal fluid escaped that the cortex gradually receded and even pul- 
sated slightly at the end of operation, so that a bilateral decompression was 
deemed unnecessary. Many punctate hemorrhages throughout the cortex. 
Usual closure with two drains 
of rubber tissue inserted. 
Duration, 55 minutes. 

Post-operative Notes. — 
Patient seemed to improve 
during the first 10 hours fol- 
lowing the operation in that 
the pulse did not descend 
below 70 and the blood-pres- 
sure remained above 104; 
patient became more con- 
scious, but never sufficiently 
to answer questions ; reflexes 
remained the same, however, 
and the fundi did not im- 
prove. Fifteen hours after 

Operation, pulse began tO Fig 98 _ wide linear fracture of left occipital bone, extending 

aSCend VerV rapidly tO 114, to the foramen magnum and through the petrous portion of the 

*; . left temporal bone in a patient having a high intracranial pres- 

temperature tO 106° rCSpi- sure, due to subdural hemorrhage and cerebral edema. Left 

subtemporal decompression and drainage failed to prevent the 
rations tO 32 and the blOOd- onset of an acute medullary edema. 

pressure descended to 112. 

Twenty hours after operation, temperature was 107°, pulse 150, respira- 
tions 40 and blood-pressure 98 — at this time, pulmonary edema became 
evident so that patient died three hours later — that is, 24 hours after opera- 
tion — from the condition of typical medullary edema and collapse. An 
X-ray picture was taken postmortem, showing the occipital fracture, the 
left decompression opening and two silver clips (Fig. 98). 

Autopsy. — Linear fracture extended from the external occipital protu- 
berance downward on the left side to the foramen magnum and then upward 
and forward through the petrous portion of the left temporal bone into the 
middle fossa (Fig. 99). No extradural hemorrhage. Diffuse subdural 
hemorrhage over both hemispheres with extensive contusion and laceration 
of right frontal lobe — "trauma an contra-coup." Xo intracerebral or ven- 
tricular hemorrhage, but much free blood and cerebrospinal fluid in the 
subtentorial fossa about the medulla. Pituitary gland itself was definitely 





336 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



enlarged — the anterior lobe itself being the size of almost a small cherry. 
Old tnbercnlons process in the right apex of lung. 

Remarks. — It has been a common observation that when these traumatic 
cranial patients merge very quickly from the condition of shock into that of 
high intracranial pressure without the patient having gone through the 
signs, clinically, of medullary compression — such as a very slow pulse- and 
respiration-rate, etc. — that these patients are most serious ones in that the 
condition of advanced medullary edema may progress so rapidly that very 
little can be done for them. This is particularly true with fractures about 
the foramen magnum and subtentorially, and the presence then of a higli 
temperature within 8 hours after the injury is frequently observed in such 
posterior basal fractures — as though the heat centers in the basal ganglia 
were irritated. It would seem in this patient that the operation had really 

been performed during the 
early stage of medullary 
edema, for although the 
intracranial pressure was 
high yet the pulse was at 
its lowest level, only 74, 
and therefore confirming" 
the opinion that the patient 
advanced very rapidly from 
the condition of shock into 
that of medullary edema 
without exhibiting clinically 
the signs of medullary com- 
pression. A bilateral sub- 
temporal decompression 
might have been performed 
upon this patient on account 
of the very high intracranial 
pressure ascertained at 
operation, and yet I feel that the end-result would have been the same in 
view of the autopsy findings in the subtentorial cavity about the medulla. 
There are no more serious cranial injuries than those located in this region. 
The rupture and operative laceration of the cortex beneath the Sylvian 
fissure upon enlarging the dural opening should have been prevented techni- 
cally, and it now can be : if the dura is under very high tension so that 
upon incising it the underlying cortex might rupture as in this patient, a 
lumbar puncture is now performed and the cerebrospinal fluid is allowed 
to escape, and it is surprising how quickly the intradural pressure can 
usually be lowered so that it makes the opening of the dura a practically 
safe procedure and the underlying cortex naturally does not rupture. 
At times, through a very small dural incision, a ventricle puncture needle 
may be used to permit the escape of cerebrospinal fluid from the ventricles 
and in this manner the intradural pressure is lowered so that the dural open- 
ing may be safely enlarged ; however, a ventricular puncture should only be 
performed when absolutely necessary, and if a lumbar puncture is possible, 




Fig. 99. — Photograph of the cranial fracture of the patient 
showing the extensive linear fracture of the left half of the 
occipital bone, extending into the petrous portion of the left 
temporal bone; the lower half of the bony opening of the left 
decompression with its drain of rubber tissue is clearly shown. 



ACUTE BRAIN INJURIES 337 

then the latter is preferable for this purpose of lowering the intradural 
pressure — the dura having been exposed and a small incision made in it. 
The danger of an acute medullary compression in the foramen magnum by 
the withdrawal of cerebrospinal fluid at lumbar puncture is practically nil 
when a small dural incision has been made previously, as in the subtemporal 
decompression. The ventricular puncture through a decompression opening 
necessitates the piercing of the cerebral cortex and subcortically in order 
to reach the ventricle, and it must cause a certain amount of cerebral damage, 
even though it is not demonstrated clinically ; I believe that such punctures, 
therefore, should only be performed when absolutely necessary. 

Case 73. — Acute severe brain injury associated with high intracranial 
pressure due to extradural, subdural and cortical hemorrages. Left sub- 
temporal decompression and drainage. Death. Autopsy. 

No. 274. — George. Forty years. White. Married. Manager. Scotland. 

Admitted June 4, 1915, Polyclinic Hospital. 

Operation (June 5, 1915 — 19 hours after injury). — Left subtemporal 
decompression and drainage. 

Died June 8, 1915 — 78 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Patient was found lying unconscious upon the curbing. 
As there was an odor of alcohol upon his breath, he was arrested for alco- 
holism and was confined in a cell at the police-station for 6 hours ; not becom- 
ing conscious, he was transferred to the hospital in the ambulance. 

Examination upon admission (7 hours after injury). — Temperature, 
99.2° ; pulse, 86; respiration, 20; blood-pressure, 110. Unconscious, but can 
be aroused by the fumes of ammonia ; cannot talk. Alcoholic f acies ; the 
odor of alcohol still upon his breath. Hematoma over left parieto-occipital 
area. Bleeding from left ear and nose ; extensive left mastoid ecchymosis. 
Pupils moderately dilated, equal and react normally. Reflexes — patellar 
present and equal ; no ankle clonus nor Babinski ; abdominal reflexes not 
elicited. Fundi — retinal veins slightly enlarged; no definite blurring of 
the margins of optic disks, but a general haziness throughout both retinae. 

Treatment. — Expectant palliative ; routine shock measures instituted. 
The low blood-pressure associated with no marked signs of intracranial 
pressure indicated a mild degree of shock being present and the patient was 
treated expectantly in the belief that a good recovery could thus be obtained. 
Within 6 hours, however, the pulse descended to 60, blood-pressure rose to 
130, and a definite weakness of the right side of face and right arm appeared 
with an incomplete motor aphasia. (Patient was ascertained to be right- 
handed as were his parents, brothers and sisters.) 

Examination (11 hours after admission and 18 hours after injury). — 
Temperature, 100.2°; pulse, 48-50; respiration, 14; blood-pressure, 150. 
Profound unconsciousness. Discharge of blood and cerebrospinal fluid from 
the left ear had ceased 6 hours before ; otoscopie examination reveals a lacera- 
tion of the posterior quadrant of the left tympanic membrane. Marked 
weakness of right side of face (cortical in type) and of righl arm. though no 
paresis of right leg could be elicited. Pupils — left much larger than right 



338 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and does not react to light. Reflexes: patellar — right greater than left; 
right exhaustible ankle clonus and suggestive right Babinski; abdominal 
reflexes absent. Fundi— retinal veins slightly enlarged ; no definite blurring 
of margins of optic disks but a general retinal haziness throughout and not 
limited to the optic disks. Lumbar puncture — blood-tinged cerebrospinal 
fluid under slightly increased intracranial pressure (14 mm.). 

Treatment. — The clinical picture was very confusing and puzzling in that 
a patient, having a head injury, whose pulse was as low as 40 and respirations 
14, with a blood-pressure rising from 110 to 150, indicating a high intra- 
cranial pressure and still increasing, and yet the ophthalmoscopic examina- 
tions were practically negative and the pressure of the cerebrospinal fluid as 
estimated at lumbar puncture was only moderately increased. For fear 
a medullary edema might be precipitated unless an immediate decompression 
was performed, this operation was considered advisable, and upon the left 
side on account of the mild motor aphasia, paresis of right side of face and 
of the right arm, increased right reflexes and a dilated left pupil. 

Operation (12 hours after admission and 19 hours after injury). — 
(Pulse, however, was now 66 and respiration 18 and rather weak and shallow, 
so that medullary edema was feared.) Left subtemporal decompression (no 
anesthesia being necessary) : usual vertical incision, bone removed and no 
complications ; squamous portion of temporal bone contained several irregu- 
lar lines of fracture running antero-posteriorly and vertically ; the posterior 
portion of the fractured bone was depressed downward toward the petrous 
portion of temporal bone. Small extradural clot evacuated. Dura tense and 
bluish, and upon incising it dark bloody cerebrospinal fluid spurted a dis- 
tance of 1 inch, and upon enlarging the dural opening many dark syrupy 
clots oozed out. Cortex very much congested throughout with many punctate 
hemorrhages. At lower anterior portion of the left temporal lobe, there 
was a laceration about 2 cm. in length. As the cerebral tension was very high 
and there was not a large amount of cerebrospinal fluid escaping, an effort 
was made to tap the ventricle through the lacerated cortical area but it was 
unsuccessful; however, by the end of the operation sufficient cerebrospinal 
fluid had escaped to permit the cerebral cortex to become less tense and to 
pulsate. Usual closure with 2 drains of rubber tissue inserted. Duration, 
45 minutes. 

Post-operative Notes. — At the end of the operation, the temperature 
was 101.4°, pulse 98, respiration 22, blood-pressure 138; at the time, I felt 
that medullary edema had not occurred but that the rise in the pulse- and 
respiration-rates and the lessening of the blood-pressure were merely due to 
the operation itself. However, the general condition of the patient gradually 
became worse, so that 20 hours after operation the temperature was 103.6°, 
pulse 116, respiration 32, blood-pressure 120, and this condition rapidly 
progressed — a typical medullary edema and collapse; at 42 hours after 
operation, the temperature was 106.4°, pulse 154, respiration 44, blood- 
pressure 106, and yet owing to the excellent resistance of the patient he did 
not die until 78 hours after operation. 

Autopsy. — Irregular line of fracture from left vertex down into decom- 
pression area and then into left petrous bone to the internal auditory meatus 



ACUTE BRAIN INJURIES 



339 



and then backward along the basilar process into the anterior margins of the 
foramen magnum (Fig. 100). Thin layer of subdural blood over both hemi- 
spheres, and subtentorially about the medulla were much dark blood and 
bloody cerebrospinal fluid exerting direct compression upon the medulla 
itself. Punctate hemorrhages throughout the anterior portion of cortex of 
left hemisphere and a small laceration in the posterior portion of the third 
left frontal convolution (Broca's motor speech area). Ventricles negative. 

Remarks. — This case was very instructive ; a man considered as an alco- 
holic merely because he is unconscious and there is an odor of alcohol upon 
his breath, is first taken to the police station, then removed to the hospital 
where careful examinations reveal no signs of a definite increase of intra- 
cranial pressure and yet the pulse and respiration gradually became lower 
and lower and then, when the pulse does reach 48 and the respirations 14, 
it is considered necessary to perform 
a decompression even though the 
ophthalmoscopic examination reveals 
only slight increase and the lumbar 
puncture only a moderate increase of 
the intracranial pressure. The opera- 
tion was not performed until the signs 
of an early medullary edema had 
already appeared and the patient died, 
as all these patients do, when medul- 
lary edema occurs after the pulse 
has reached its lowest level of medul- 
lary compression. 

The autopsy findings " clear up" 
the puzzling clinical signs which 
seemed paradoxical. The patient upon 
admission to the hospital was in a 
mild condition of shock, as evidenced 
by the blood-pressure of 110 and the 

pulse-rate of 86; then, as the direct compression of the medulla occurred 
from the increasing amount of subtentorial blood and cerebrospinal fluid 
being collected there, the pulse- and respiration-rates descended to 48 and 
14, respectively, and the blood-pressure ascended to 150 — typical signs of 
medullary compression, but the ophthalmoscopic examinations were practi- 
cally negative because the supratentorial pressure was not so greatly in- 
creased and the pressure of the cerebrospinal fluid as indicated by the 
lumbar puncture was also not markedly increased (as the low pulse- and 
respiration-rates would presuppose) because there was apparently a definite 
blockage at the foramen magnum, which prevented much cerebrospinal 
fluid and blood from escaping downward into the spinal canal, or the 
general intracranial pressure was in reality not high and there was only 
a high local medullary pressure. 

A suboccipital decompression, if performed earlier than the time of 
the subtemporal decompression, might have relieved the acute medullary 
compression sufficiently to have secured a recovery; the presence oi the 




Fig. 100. — Wide linear fracture extending 
from the left petrous bone posteriorly along the 
basilar process of the occipital bone to the 
foramen magnum — a most serious type of 
fracture for fear of subtentorial complications, 
as occurred in this patient. 



34 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

motor aphasia and weakness of the right side of the face and of the right 
arm made the left subtemporal decompression seem at the time the more 
rational procedure. 

The resistance of patients to intracranial injuries, and particularly to 
the effect of an increased intracranial pressure, varies very much indeed : 
children withstand them much better than adults, women apparently much 
better than men, and naturally non-alcoholic patients much better than those 
patients addicted to the daily use of alcohol; these latter patients are par- 
ticularly bad risks and the prognosis, with or without operation, is always 
very grave, in that the danger of the so-called ' ' wet ' ' brain of cerebral edema, 
and consequently a medullary edema, is very great indeed. It is for this 
reason, to a large extent, that the mortality figures of large ' ' city charity ' ' 
hospitals are very high indeed, because the vast majority of their patients 
having brain injuries are also suffering from the results of chronic alcohol- 
ism and therefore arteriosclerosis in its various forms, chronic nephritis, etc. 

If this patient could have been operated upon within two hours after 
admission, he might have had a definite chance of recovery, and it is unfor- 
tunate that the operation, when it was decided upon, could not have been 
performed within three hours after admission instead of five hours. At 
the first examination upon admission, the condition of the patient was such 
that it was felt advisable to examine him frequently in the hope that he 
would be able to "take care of" the increased pressure by the natural 
means of absorption, and this decision was considered advisable and good 
surgical judgment (as it is in many cases). In this patient, however, the 
signs of medullary compression advanced so rapidly that it would have 
been better judgment to have advised the operation earlier, and yet it was 
impossible to ascertain this fact within two hours after his admission. Yet 
when it was finally decided that an operation was imperative, it was most 
unfortunate that the operation could not have been performed immediately, 
for by the time the operation was finally begun the patient was well advanced 
into the condition of cerebral edema. I have observed this loss of most 
valuable and most important time to the patient in similar cases of brain 
injury when the patient has been allowed "to wait" over night in order 
that an X-ray picture of the fracture may be obtained; so frequently, a 
patient having the condition of mild medullary compression is thus per- 
mitted to reach the stage of medullary edema while waiting for an X-ray 
picture — of no importance either to the patient or to the doctor, so far as the 
treatment of the patient is concerned, as an operation is not advised 
according to the presence or not of a fracture of the skull ; it so frequently 
happens that the operation should be performed upon the side of the skull 
opposite to the fracture, and it is the clinical signs which determine whether 
the operation shall be a left or a right subtemporal decompression. In these 
urgent cases, if the X-ray must be taken (and I believe an X-ray picture 
should always be obtained if only for the clinical records and data), then 
by all means let it be taken several days after the necessary and appropriate 
treatment has been used — whether an operation or not; otherwise, it may 
happen, and I feel that it does frequently occur, that the X-ray picture of 
the patient has been obtained and the patient has died or has been allowed 



ACUTE BRAIN INJURIES 341 

to reach the dangerous stage of medullary edema while "waiting" for the 
appropriate operative treatment. 

Case 74. — Acute severe brain injury associated with high intracranial 
pressure due to subdural hemorrhage and cerebral edema. Left subtem- 
poral decompression and drainage. Death. Autopsy. 

No. 049. — Daniel. Forty-four years. White. Married. Salesman. U. S. 

Admitted October 21, 1913, Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Operation (October 22, 1913 — 21 hours after injury). — Left subtem- 
poral decompression and drainage. 

Died October 23, 1913 — 18 hours after operation. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — While crossing the street in an intoxicated condition, 
patient was knocked down by a trolley car ; immediate loss of consciousness ; 
brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.8°; pulse, 82; respiration, 20; blood-pressure, 146. Profoundly 
unconscious ; alcoholic and vomited profusely alcoholic mixtures three times 
upon being slightly aroused. Extensive laceration of scalp over occipital 
area. Marked ecchymosis of both orbits. Blood in the right external auditory 
canal; otoscopic examination reveals a laceration of posterior portion of 
right tympanic membrane; left tympanic membrane bluish and bulging; 
both mastoid areas ecchymosed. Pupils equal, rather contracted and do not 
react to light. Reflexes negative. Fundi negative. 

Treatment. — Expectant palliative. 

Examination (12 hours after admission). — Temperature, 99.8°; pulse, 
70 ; respiration, 16 ; blood-pressure, 150. At this examination, careful prob- 
ing of the occipital laceration reveals a fracture of the underlying bone, but 
not depressed. Patient has just had a Jacksonian convulsion, beginning 
in the right arm, then extending both to the right face and right leg ; 
contractions of the muscles lasted 3 minutes. Pupils — left much smaller 
than right and does not react to light. Reflexes: patellar — right greater 
than left ; right inexhaustible ankle clonus and double Babinski ; abdominal 
reflexes absent. Fundi — retinal veins dilated ; definite blurring of nasal 
margins of both optic disks. Lumbar puncture — bloody cerebrospinal fluid 
under high pressure (approximately 21 mm.). 

Treatment. — The onset of right-sided convulsions with the signs of an 
increasing intracranial pressure made a subtemporal decompression advis- 
able not only to lessen the intracranial pressure but also to lessen the cortical 
irritation over the left hemisphere ; on account of the right-sided convulsions, 
the increased right reflexes and the contracted left pupil, a left subtemporal 
decompression was naturally advised. Unfortunately, permission for the 
operation could not be obtained immediately, and when it was finally secured. 
the operating room was being used so that it was S hours later before the 
operation could be performed; during this time, the patient had had 14 
right-sided convulsions (none of them becoming general in character and 
each lasting not over 3 minutes), the pulse had descended to 58 three hours 



342 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




before and had now risen to 76, both optic disks were obscured by edema but 
no measurable swelling of them, and the left pupil which had been con- 
tracted was now markedly dilated — 
so that the danger of medullary edema 
was very great indeed (and as the his- 
tory of the patient shows, it had 
already begun). 

Operation (20 hours after admis- 
sion). — Left subtemporal decompres- 
sion (no anesthesia being necessary) : 
usual vertical incision, bone removed 
and no complications. Dura very tense 
and bluish; upon incising it, dark 
syrupy blood welled through opening 
and upon enlarging the dural opening, 
much of this free subdural blood and 
bloody cerebrospinal fluid escaped. 
Cortex was under such high pressure 
and protruded so tensely that two 
attempts were made to tap the ven- 
Cortex contained many punctate hem- 
During the operation, two right- 
sided convulsions oc- 
curred so that it was 
necessary to use chloro- 
form to control them. 
At end of the operation, 
the cortex could be seen 
pulsating feebly. Usual 
closure with two drains 
Wk ■ of rubber tissue. Dura- 
tion, 50 minutes. 

Post-operative Notes. 
— The temperature at 
the beginning of the 
operation had been 
102.6° and the pulse 92, 
and at the end of the 
operation it had risen to 
104.4° and the pulse to 
118 ; the general condi- 
tion rapidly became 
worse, so that 12 hours 
after operation the temperature was 106°, pulse 150, respirations 42, whereas 
the blood-pressure was only 102 — that is, all the signs of an acute medullary 
edema and collapse. Patient died 18 hours after the operation with a tem- 
perature of 108°. 



Fig. 101. — Extensive linear fractures of both 
petrous bones and of the occipital bone into the 
foramen magnum, causing a large subtentorial 
hemorrhage and direct medullary compression 
and its resulting medullary edema. 

tricles but they were unsucessful. 
orrhages but no lacerations, were visible. 



■ 





Fig. 102 — Multiple subarachnoid hemorrhages especially upon 
the orbital surfaces of both frontal lobes in a patient dying from 
acute medullary edema. 



ACUTE BRAIN INJURIES 



343 



Autopsy. — Irregular line of fracture radiated from external occipital 
protuberance downward in median line across the foramen magnum and 
forward through the basilar process of occipital bone to the posterior clinoid 
process of the sella turcica ; from this point a line of fracture radiated later- 
ally into each petrous bone (Fig. 101). Small hemorrhage beneath dura over 
both middle ears and also posterior to both orbits. Much subdural free blood 
with much hemorrhage and clotted blood subtentorially about cerebellum 
and medulla itself; extensive lacerations and cortical hemorrhage in both 
frontal lobes, especially the orbital surfaces (Fig. 102). Both middle ears 
contain clotted blood and 
there was also free 
hemorrhage in both pos- 
terior orbital cavities. 
Ventricles negative. A 
photograph was taken 
at the end of the au- 
topsy to show the exten- 
sive mastoid ecchymosis 
(Fig. 103). 

Remarks. — The rapid 
onset of medullary 
edema in this patient 
was undoubtedly the 
result of the direct med- 
ullary compression of 
the subtentorial hemor- 
rhage due to the occipi- 
tal fracture extending 
through the foramen 
magnum. These are 
most serious fractures 
and most frequently 
cause death from the 
resulting subtentorial hemorrhage, acutely compressing the medulla itself. 

No definite localizing cause was found to account for the right-sided 
convulsions as the cortex of both hemispheres appeared macroseopieally to 
be similarly affected; these negative findings to account for localized con- 
vulsions and other signs of focal cortical irritation are unfortunately only 
too common in brain injuries — whether due to localized edema as seems 
very possible in most cases, or that certain areas of the cortex are more 
susceptible to irritation in some people than in others, may also be a 
factor in their occurrence. It is, however, not so essential to attempt to 
remove the irritation itself from the particular area of the cortex affected 
as it is to lessen the general intracranial pressure by means of a subtem- 
poral decompression, especially over the hemisphere involved, and by this 
means the local irritation is also lessened. 

It was very interesting in this patient to observe the pupillary changes; 
at first, both pupils were slightly contracted and equally so. due to the mild 




Fig. 103. — The post-mortem photograph after completion of 
autopsy exhibiting the multiple contusions of the scalp and the 
extensive mastoid ecchymosis. 



344 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

irritative presence of the cortical hemorrhage. (Shock not being an impor- 
tant factor in this patient, the pupils were not dilated as they usually are ; 
alcoholism undoubtedly tends to lessen the initial shock in head injuries.) 
As the cortical irritation increased, and especially over the left hemisphere 
more than the right, the left pupil became more contracted than the right 
pupil; however, as the cortical irritation over the left hemisphere became 
overshadowed by the pressure of the increasing supracortical hemorrhage, 
thel signs of cortical irritation changed to those of a cortical paralysis of 
pressure — that is, the contracted left pupil now became dilated and much 
larger than the right pupil, and naturally with no reaction to light. This is 
a fairly constant pupillary phenomenon and it is a definite aid to cortical 
localization, especially in the absence of external factors such as morphia, etc. 

The otoscopic findings of a lacerated right tympanic membrane and 
merely a bluish and bulging left tympanic membrane were confirmed at the 
autopsy in that a line of fracture extended through the tegmen tympani 
of both petrous bones and yet the left tympanic membrane escaped being 
ruptured. It is surprising that no cerebrospinal fluid was observed in the 
discharge from the right ear, and yet that is a fairly frequent observation 
even in the presence of a line of fracture into the middle ear and the profuse 
discharge of blood from the external auditory canal ; it would seem that in 
some of these patients, the dura overlying the line of fracture in the petrous 
bone is not torn and therefore there is no escape of cerebrospinal fluid. 

Case 75. — Acute severe brain injury associated with high intracranial 
pressure due to subdural hemorrhage and cerebral edema. Right subtem- 
poral decompression and drainage. Death. Autopsy. 

No. 430.— Frank. Thirty-eight years. White. Single. Thug. U. S. 

Admitted November 19, 1915, Polyclinic Hospital. 

Operation (November 20, 1915 — 26 hours after injury). — Right sub- 
temporal decompression and drainage. 

Died November 21, 1915 — 32 hours after operation. 

Family history negative. 

Personal History. — "Strong-arm" man with a bad reputation; twice 
in Sing Sing. 

Present Illness. — Patient was found in an alley- way following a fight 
between rival "gangs"; unconscious from a head injury due to blackjack; 
brought to hospital in the ambulance. 

Examination upon admission (about 2 hours after injury). — Tempera- 
ture, 99°; pulse, 58; respiration, 16; blood-pressure, 118. Well-developed 
and nourished. Unconscious. Bleeding from the right ear and from the nose ; 
no mastoid ecchymosis. A very superficial laceration of the scalp in the 
median occipital region. Pupils — very much contracted and no reaction to 
light (morphine believed to be the cause) . Reflexes — both legs very rigid and 
it was impossible to elicit either patellar reflex; double exhaustible ankle 
clonus ; right Babinski with a suggestive left Babinski ; abdominal reflexes 
absent. Fundi — retinal vessels enlarged ; nasal margins of both optic disks 
blurred. Lumbar puncture — blood-tinged cerebrospinal fluid under a 
moderately increased pressure (approximately 14 mm.). 

Treatment. — Expectant palliative; careful observation. It was hoped 



ACUTE BRAIN INJURIES 



345 



that the increased pressure, as shown in the lowered pulse-rate and by the 
ophthalmoscopic examination and the lumbar puncture, could be "taken 
care of" by the normal means of absorption; the lowered blood-pressure 
of 118, due most probably to the initial shock of the head injury, was a 
definite contra-indication for operation. During the next 8 hours, the pulse 
slowly increased as high as 76 and the general condition of the patient 
improved — the blood-pressure rising to 130 ; at this time, however, the pro- 
fuse bleeding from right ear and nose stopped, and within 2 hours the pulse 
gradually descended, while the blood-pressure continued to increase until 
the following examination was made. 

Examination (22 hours after admission). — Temperature, 102°; pulse, 
50 ; respiration, 14 ; blood-pressure, 142. Profound unconsciousness. Bleed- 
ing from the right ear has 
ceased; otoscopic examina- 
tion reveals a small laceration 
of the posterior lower quad- 
rant of the right tympanic 
membrane. Pupils — right 
widely dilated and does not 
react to light. Reflexes — pa- 
tellar greatly exaggerated 
with double patellar clonus 
(both legs being very rigid 
and could not be flexed) ; 
double ankle clonus and dou- 
ble Babinski ; abdominal re- 
flexes absent. Fundi — retinal 
veins dilated ; papilledema of 
1 diopter — both nasal halves 
and temporal halves being 
obscured. Lumbar puncture 
— blood-tinged cerebrospinal 
fluid under high pressure 
(approximately 22 mm.). 

Treatment. — An immediate right subtemporal decompression advised in 
the hope that the acute medullary compression could be relieved before the 
signs of medullary edema occurred and thus this great danger be avoided : 
the dilated right pupil, together with the fact that the patient and his rela- 
tives all were right-handed, and there being no other localizing signs, a 
right rather than a left subtemporal decompression was deemed advisable ; 
the line of fracture extending' into the right ear was of no localizing aid to 
the intracranial lesion. However, before preparations for the operation 
could be completed, the pulse, within a period of two hours, had risen 
rapidly to 76, while the blood-pressure had descended to 124: nevertheless. 
in spite of these signs of an approaching medullary edema, the operation 
was hurriedly performed. 

Operation (24 hours after admission V — Right subtemporal decompres- 
sion (no anesthesia being necessary') : usual vertical incision, bone removed, 




u 



Fig. 



104.- — Extensive wide linear fracture of occipital bone 
just to the right of the midline, in a patient upon whom the 
operation of right subtemporal decompression was performed 
in the hope that an acute medullary edema could be prevented 
Two silver clips can be seen within the oval bony defect of the 
right subtemporal decompression. 



346 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



and no complications. Dnra tense and bluish, and upon incising it, a large 
amount of dark syrupy subdural blood welled out ; upon enlarging the 
dural opening, many dark subdural clots extruded, revealing a swollen 
cortex which tended to protrude but did not rupture ; rather ' ' dry ' ' brain, 
but owing to the loss of a large amount of supracortical free blood, the 
cortex could be seen pulsating slightly at the end of the operation. No 
punctate hemorrhages nor cortical lacerations visible. Usual closure with 
two drains of rubber tissue inserted. Duration, 35 minutes. 

Post-operative Notes. — The general condition of the patient did not be- 
come worse during the first 12 hours after operation — the pulse remained 
under 80 and the blood-pressure not lower than 120, but then the condition of 
the patient rapidly changed so that 20 hours after operation the temperature 
was 105.4°, pulse 132, respiration 34 and blood-pressure 110 — a pronounced 

condition of medullary edema. The 
usual course followed — temperature 
rising to 108°, pulse 160 plus, respi- 
rations 48, while the blood-pressure 
descended to 80 and below, when death 
occurred 32 hours after operation. 
A rontgenogram was taken postmor- 
tem for comparison with the autopsy 
findings (Fig. 104). 

Autopsy. — Linear fracture ex- 
tended downward from occipital pro- 
tuberance into posterior margin of 
foramen magnum and then from the 
anterior margin of foramen magnum 
forward along the right edge of the 
basilar process to the tip of the right 
petrous bone, where it turned at right 
angles into petrous portion of right 
temporal bone (Fig. 105). Blood in 
the right middle ear. Layer of) dark blood over both hemispheres — more 
over left. Both anterior portions of frontal lobes contused and slightly 
lacerated — left more than right; many subarachnoid hemorrhages (Fig. 
106). Much clotted blood subtentorially about the cerebellum and medulla 
— the medulla being forced downward into the foramen magnum where it 
apparently blocked the entire lumen. Ventricles negative. 

Remarks. — It would seem that a suboccipital decompression would have 
offered this patient a greater chance of recovery if performed earlier — 
before the pulse had reached its lowest level and therefore before the signs 
of a beginning medullary edema had appeared ; this operation however, is a 
much more formidable one than the subtemporal decompression, and the signs 
of an acute direct medullary compression occur so rapidly and progress 
so quickly into the stage of medullary edema that it is most unusual for a 
suboccipital decompression to be deemed advisable ; besides, even in these 
patients having an acute direct medullary compression but of mild severity, 
the subtemporal decompression undoubtedly suffices to obtain a good recov- 




Fig. 105. — Extensive linear fracture of right 
petrous bone and of the occipital bone extending 
into foramen magnum anteriorly and posteriorly 
— the most serious type of fracture on account 
of the frequent medullary complications of direct 
pressure of hemorrhage and edema. 



ACUTE BRAIN INJURIES 



347 



ery of the patient, and as the subtemporal decompression is a comparatively 
"safe" operation, and of very little shock to the patient, naturally it is 
usually advised. When not successful and the patient dies and similar 
autopsy findings as in this patient are disclosed, then it is very easy to 
assert that a suboccipital decompression was indicated and would have proved 
sufficient for a recovery of life. If a subtemporal decompression with drain- 
age and, if necessary, a bilateral decompression had been performed 6 hours 
earlier, when the pulse was descending from 76 to 60 and the signs of an 
increasing intracranial pressure were becoming more marked, rather than 
waiting until morning when the pulse had descended to 50 (its lowest level 
as it proved), possibly even in this patient a recovery might have been 
obtained, as the subtentorial pressure and even the direct compression of 




Fig. 106. — Multiple subarachnoid hemorrhages upon the inferior surfaces of both frontal lobes in a paiient 
dying of acute medullary edema following a medullary compression of subtentorial hemorrhage. 

the medulla might have been lessened. There are no cases in surgery 
requiring immediate treatment so much as patients having brain injuries 
with a high increase of the intracranial pressure, and the successful treat- 
ment of ones having a high intracranial pressure requires most careful and 
repeated examinations and observations, and if the increased pressure can- 
not be controlled and lessened by the expectant palliative measures, then an 
early mechanical relief by means of a decompression is urgently required 
and should be performed without delay. 

The unusually low initial pulse-rate of 58 in this patient, while the blood- 
pressure was only 118, would tend to indicate even then a direct medullary 
compression ivhile the blood-pressure itself was influenced, temporarily at 
least, by the initial shock. In future patients, this initial low pulse com- 
bined with a low blood-pressure will have a greater significance. 

The markedly contracted pupils observed upon admission were undoubt- 



348 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

edly due to the cortical irritation of the subdural hemorrhage, and as the 
intracranial pressure became higher and more over the right cortical hemi- 
sphere, the right pupil naturally became dilated from the paralytic effect 
of this supracortical pressure. 

The spasticity of both legs to the extent of a marked stiffness, and also 
slightly of the arms, is a very serious prognostic sign in these patients having 
brain injuries in that they usually die within 24 hours after its appearance ; 
it may be due to extreme intracranial pressure, but it is more probably 
the result of high intracranial pressure causing an edema of the pyramidal 
tracts and particularly of the medulla itself, so that this extreme degree 
of bilateral spasticity occurs. The autopsy findings of the medulla being 
"choked" and "collared" in the foramen magnum would tend to confirm 
this observation; also the presence of a subtentorial fracture and thus the 
greater danger of subtentorial lesions with high direct medullary compres- 
sion, is usually ascertained in these patients having a high degree of 
bilateral spasticity. 

The "contre-coup" effect of cranial injuries upon the brain is again 
illustrated in this patient — the area of contact being in the occipital region 
and the fracture extending from there along the base to the right ear, and 
yet it is not the underlying or overlying cortex that is damaged but the 
anterior portions of both frontal lobes, and particularly the left lobe, which 
are contused and lacerated. However, it is the presence of an increased 
intracranial pressure which determines the necessity of a subtemporal de- 
compression, and not the presence or not of cortical contusions and lacera- 
tion; also, it is not necessary nor practicable in most patients having 
brain injuries to operate directly over the cortical lesion, but rather to 
relieve the high intracranial pressure by means of a subtemporal decom- 
pression over the hemisphere of the higher pressure — whether the under- 
lying cortex is contused or lacerated or not, and it matters not where the 
linear fracture of the skull is or whether it is present at all ; if there are no 
localizing signs of greater increased intracranial pressure over either hem- 
isphere, then naturally the subtemporal decompression is performed on the 
right side in patients who are right-handed, and on the left side in the patients 
who are left-handed. 

The accurate estimation of the increasing intracranial pressure, as regis- 
tered by the lumbar puncture, is clearly illustrated by the test made upon 
the patient ? s admission to the hospital when the pressure was approximately 
14 mm., and then 22 hours later when the signs of definite papilledema had 
occurred in both fundi, the pressure at lumbar puncture had risen to approx- 
imately 22 mm. This test is now more accurately registered by the use of the 
spinal mercurial manometer and this instrument is a most valuable one for 
the accurate registration of increased intracranial pressure of varying degree. 

Case 76. — Acute severe brain injury associated with a fracture of the 
base of the skull and extreme intracranial pressure; extradural, subdural 
and intracerebral hemorrhages and cortical lacerations; medullary com- 
pression and incipient medullary edema. Left subtemporal decompression 
and drainage. Medullary edema ; death. Autopsy. 

No. 1026.— Gertrude. Fifteen years. White. School. U. S. 






ACUTE BRAIN INJURIES 349 

Admitted October 29, 1918 — 5 hours after injury. Audubon Hospital. 
Referred by Doctor George Barrie. 

Operation (October 29, 1918 — 1 hour after admission). — Left subtem- 
poral decompression and drainage. 

Died October 30, 1918 — 7 hours after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While ' ' running an errand" early this evening (7 p.m.) , 
patient was found lying upon the pavement near the curbing in a stuporous 
condition; she was carried into her home, regained complete consciousness 
almost immediately, said that her head "hurt" her, but was unable to state 
how the injury had occurred ; small amount of bleeding from left ear, asso- 
ciated with a left mastoid ecchymosis; she became sleepy — "dozed off to 
sleep," and the patient was not considered to be seriously injured until 
3 hours later, when it was ascertained that she could not be aroused to 
consciousness; the pulse had become 66 and the respirations 14 and of an 
irregular character, while convulsive twitchings of the entire right side of 
the body now appeared. 

Examination (3 hours after injury — in consultation with Doctor Barrie) . 
— Temperature, 99.4° ; pulse, 64 ; respiration, 16 ; blood-pressure, 128. Well- 
developed and nourished. Profound unconsciousness with extreme spastic- 
ity of both legs and partially of both arms — almost the rigidity of opisthot- 
onus; tetanic twitches throughout body — right side more than left. Small 
amount of clotted blood in left auditory canal; otoscopic examination re- 
vealed a laceration of the lower posterior quadrant of the left tympanic 
membrane; extensive left mastoid ecchymosis. Pupils — left pupil widely 
dilated, while the right pupil was contracted to pin-point size, and neither 
reacts to light. Reflexes — patellar very much exaggerated, with double 
patellar clonus; double ankle clonus and double Babinski; abdominal re- 
flexes absent. Fundi — retinal veins full, tortuous and buried in edematous 
tissue in places ; double papilledema of 1 diopter swelling — both nasal and 
temporal halves of the optic disks being obscured by edema but not to the 
extent of producing "choked disks" (a swelling of 2 diopters plus). 

Treatment. — In the presence of these signs of high intracranial pressure 
of sufficient amount to produce the definite condition of medullary com- 
pression associated with a bilateral spasticity and epileptiform seizures of 
cortical irritation, an immediate removal of the patient to a hospital was 
advised so that the patient could have the benefit of a subtemporal decom- 
pression if her condition then warranted it — the danger of an acute medul- 
lary edema being very great indeed. 

Examination upon admission to Audubon Hospital (4 hours after 
injury). — Temperature, 101°; pulse, 88; respiration, 28; blood-pressure; 
126. Profound unconsciousness continues ; the spasticity is possibly not so 
marked and no convulsive seizures. Pupils — both dilated and do not react 
to light. Reflexes — patellar very much exaggerated with double patellar 
clonus; double ankle clonus and double Babinski ; abdominal reflexes cannot 
be elicited. Fundi — retinal veins engorged and buried in places in ode- 



350 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



inatous retina ; double "choked disks" of 3 diopters swelling'. Lumbar punc- 
ture — bloody cerebrospinal fluid under high pressure (23 mm.). 

Treatment. — For fear of the onset of an acute medullary edema, an 
immediate left subtemporal decompression and drainage advised — the rela- 
tives being informed that the patient's chances of recovery were very small 
but that the operation to lessen the high intracranial pressure did offer some 
hope and that it was the only form of treatment which might be beneficial. 
Operation (5 hours after injury). — Left subtemporal decompression and 
drainage (before the operation could be started, however, the pulse had 
ascended to 110 and the respiration to 34, while the blood-pressure had 
descended to 120 — the signs indicative of an early medullary edema ; it was 
still hoped that the immediate relief of the high intracranial pressure might 

aid the patient to recover, 
and it was therefore 
hurriedly performed) : usual 
vertical incision, bone re- 
moved and no complications ; 
temporal muscle beneath the 
temporal fascia was hemor- 
rhagic and therefore a frac- 
ture of the underlying bone 
was revealed upon retrac- 
tion of the muscle fibres ; this 
fracture extended trans- 
versely through the upper 
portion of the left squamous 
bone and through it was ooz- 
ing much free blood; upon 
removing the bone, a large 
extradural hemorrhage was 
revealed and evacuated. At 
the lower anterior angle of 
the bony opening, the under- 
lying dura was found to be 
torn — also the main branch of the left middle meningeal artery which 
was spurting freely; a small gauze tape was used to control this bleeding 
temporarily. Through the dural opening much dark currant- jelly blood 
was being* extruded, together with macerated cerebral tissue; the dura 
was now widely opened, exposing much subdural blood, and through several 
cortical lacerations welled dark blood-clots. The escape of this free hemor- 
rhage and cerebrospinal fluid permitted the cortex to bulge less tensely so 
that a definite pulsation was visible. L'sual closure with 3 drains of rubber 
tissue inserted. Duration, 38 minutes. 

Post-operative Notes. — At the end of the operation, the temperature was 
102°, pulse 140, respiration 36, while the blood-pressure had descended to 
112 ; the patient did not recover consciousness and 2 hours after operation, 
convulsive twitchings began again on the right side of the body; the rest- 
lessness was extreme. The general condition of the patient rapidly became 




Fig. 107. — Oval bony defect of left subtemporal decompres- 
sion in a patient dying from an acuts medullary edema. Opera- 
tion advised in the hope that the advancing medullary edema 
could be checked. 



ACUTE BRAIN INJURIES 



35i 



worse in that the temperature ascended to 106°, pulse and respiration to 150 
and 44, respectively, while the blood-pressure descended below 100 — the typi- 
cal chart of an acute medullary edema approaching the exitus ; patient died 
7 hours after operation. A roentgenogram was taken postmortem for com- 
parison with the autopsy findings (Fig. 107). 

Autopsy. — Linear fracture extended transversely from the left external 
orbital angular process backward through the left squamous bone and then 
downward through the left petrous bone across the sella turcica to the 
foramen ovale in the right middle fossa (Fig. 108) . Small amount of extra- 
dural hemorrhage lay beyond the margins of the left subtemporal decom- 
pression. A thin film of supracortical hemorrhage over both cerebral 
hemispheres, with extensive lacerations of the left frontal lobe and left 
temporo-sphenoidal lobe, while the tip of the right temporo-sphenoidal lobe 
was contused {''trauma au contre- 
coup"). In the posterior portion of 
left frontal lobe was an intracerebral 
hemorrhage of 4 cm. in diameter. Both 
the cerebrum and cerebellum were 
very edematous and "water-logged" 
with much free blood beneath the ten- 
torium; the medulla itself was dis- 
tinctly edematous. Ventricles negative. 

Remarks,-- -This patient again 
illustrates the futility of cranial opera- 
tions upon patients who have reached 
the stage of medullary edema ; it is 
useless to operate upon these patients 
after they have passed through the 
stage of medullary compression and 
have reached the condition of medul- 
lary edema, as indicated by the rapidly 
increasing pulse- and respiration- 
rates, high temperature and lowering of the blood-pressure. It would have 
been better surgical judgment to have refused to operate upon this patient 
after all preparations for the operation had been made and when it was 
ascertained that the condition of the patient had changed so rapidly from 
that of the preceding examination ; and yet it is most difficult not to advise 
the operation even at this late stage, because it is definitely known that the 
patient will die if nothing is done, and that possibly the patient might have 
a chance of recovery if the operation is immediately performed before the 
medullary edema has advanced to a severe degree ; this reasoning, however, 
is faulty and illogical, and it is poor surgical judgment to advise a cranial 
operation upon these patients after they have reached this stage of acute 
medullary edema. 

The variation of the pupil in this patient is very interesting and instruc- 
tive: the widely dilated left pupil associated with the contracted right pupil 
indicated the paralytic compressive effect over the left cerebral cortex and 
the irritative effect of a smaller supracortical hemorrhage over the right 




Fig. 108. — Extensive basilar fracture of the 
middle fossae and across the sella turcica in a 
patient having large extradural, subdural and 
intracerebral hemorrhages and cortical lacera- 
tions — the resulting increased intracranial pres- 
sure producing an early medullary edema. 



.352 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

hemisphere ; as this supracortical pressure over the right hemisphere in- 
creased, then the right pupil became dilated — indicating an extreme intra- 
cranial pressure of supracortical character. If this increased intracranial 
pressure could have been lessened by the operation to a marked extent, 
then the left pupil would undoubtedly have become smaller and thus 
indicating the subsidence of the paralytic effect of a left supracortical 
hemorrhage, and if a bilateral decompression had been performed, then the 
right pupil would also have become smaller; in this patient, however, the 
cerebral edema and intracranial hemorrhage were of such large amount 
and the condition of the patient had advanced so far into the condition of 
acute medullar}^ edema, that the operation in itself was not of sufficient 
decompressive effect at this late stage to produce any marked improvement. 

The bilateral spasticity observed within 3 hours after the injury was a 
bad prognostic sign, especially when so severe as to cause a mild degree 
of opisthotonos ; it indicates not merely an extreme cortical irritation but 
also an edematous compression of the pyramidal tract fibers, and it is rare 
for these patients to recover; I have not had one patient in this series of 
acute brain injuries recover in whom this condition of marked bilateral 
spasticity has been observed. 

The cessation of the convulsions at the time of the patient's admission 
to the hospital and also a lessening of the bilateral spasticity indicated that 
the cortical irritation had been submerged by an increasing supracortical 
pressure, so that the signs of cortical irritation, especially the convulsive 
twitchings, disappeared; in this connection, it is interesting to note that 
the convulsive twitchings returned to the right side of the body within 
2 hours after the operation, when the pressure over the left cerebral cortex 
at least had been lessened, and it was thus possible for the cortical irritation 
to be again exhibited. 

B. Bilateral decompression. 

Case 77. — Acute severe brain injury with signs of high intracranial 
pressure due to subdural hemorrhage and cerebral edema. Bilateral decom- 
pression and drainage. Medullary edema; death. Autopsy. 

No. 191. — Dennis, Forty-eight years. White. Married. Laborer. Ireland. 

Admitted October 30, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operations (October 30, 1914 — 5 hours after injury). — Bilateral 
decompression and drainage. 

Died November 1, 1914 — 22 hours after operations. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — Three hours ago, patient fell headlong from doorstep — 
a distance of 5 feet, striking his head upon the cement pavement ; immediate 
loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (3 hours after injury). — Temperature, 
99.8° ; pulse, 50; respiration, 14 ( Cheyne-Stokes type) ; blood-pressure, 148. 
Profound unconsciousness. Contusion and laceration of scalp over left 
frontal area ; left orbit ecchymotic and extensively swollen. Bleeding from 
nose, mouth and left ear. Pupils — left larger than right and does not react 



ACUTE BRAIN INJURIES 



353 



to light. Reflexes — patellar very much exaggerated but apparently equal ; 
no ankle clonus nor Babinski; both cremasteric and abdominal reflexes 
absent. Fundi — dilated retinal veins; papilledema of both optic disks but 
having a measurable swelling of only one diopter — that is, not a fully de- 
veloped ' ' choked disk. ' ' 

Treatment. — The patient being right-handed and the only localizing 
sign being a dilated left pupil (which tended to indicate that the left cerebral 
hemisphere was compressed more than the right), it was decided that a right 
subtemporal decompression was immediately advisable in order to lessen the 
high intracranial pressure and prevent the condition of acute medullary 
compression from merging into an acute medullary edema. While prepara- 
tions for the operation were being completed, the pulse descended to 48 as its 
Lowest level, but by the time 
the operation was begun, the 
pulse had ascended to 70, 
while the blood-pressure had 
fallen to 134 — thus indica- 
ting* even at this early date 
the probable onset of acute 
medullary edema; in the 
belief, however, that the 
patient might yet have a 
chance of recovery by means 
of an operation (an opinion 
now known to be mistaken ) , 
the operation was performed. 
A rontgenogram was made 
while waiting for the opera- 
ting-room to be prepared 
(Fig. 109). 

First Operation (2 hours 
after admission and 5 hours 
after injury). — Right subtemporal decompression; usual vertical incision, 
bone removed and no complications. Dura very tense and upon incising it, 
clear cerebrospinal fluid spurted under high pressure ; upon enlarging dural 
opening, the edematous "wet" cortex protruded under high tension but 
did not rupture; no cortical hemorrhage nor laceration visible and the 
brain became comparatively "dry," but remained very much swollen and 
"water-logged." As only a moderate amount of cerebrospinal fluid had 
escaped and since the pulsation of the cortex was very slight, it was decided 
to perform immediately a left subtemporal decompression. Usual closure 
with 2 drains of rubber tissue inserted. Temporary sterile dressing applied. 

Second Operation (immediately after first operation). — Left subtem- 
poral decompression: usual vertical incision, bone removed, and no com- 
plications. Dura very tense and bluish; upon incising the dura, dark blood 
spurted a distance of 1 foot for a period of a minute ; upon enlarging 
dural opening, large dark clots welled out so that the underlying cortex 
which was concave due to the compression of the overlying clots now 
23 




Fig. 109. — Curvilinear fracture of left occipital bone, extend- 
ing into left petrous bone, in a patient having an extreme 
intracranial pressure precipitating a medullary edema. A 
bilateral subtemporal decompression was advised in the mis- 
taken belief that a recovery of life was possible. 



354 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



became gradually convex. Dark clots, the size of cherries, continued to 
well into opening from above, though no cortical hemorrhage or laceration 
was visible in this area. At the end of operation, however, so much blood and 
cerebrospinal fluid had escaped that the intradural tension was much less 
and the cortex pulsated fairly normally. Usual closure with 2 drains of 
rubber tissue inserted. Duration, 85 minutes. 

Post-operative Notes. — Before the operation was finished, the pulse had 
ascended to 78 and, within 6 hours after operation, the pulse had risen to 
110, respirations to 30, while the blood-pressure had descended to 104; the 
general condition of the patient rapidly became worse so that patient never 
regained consciousness; 16 hours after operation, the temperature was 106°, 
pulse 160, respiration 38, and the blood-pressure 90; the patient died 22 
hours after operations. 

Autopsy. — A curvilinear fracture extended through the left occipital 

bone forward and obliquely down- 
ward into the left squamous bone and 
then into the left petrous bone — end- 
ing near the left internal auditory 
meatus (Fig. 110). Only a small 
amount of subdural bood was present, 
but the cerebral cortex was very much 
swollen and hemorrhagic throughout. 
Much free blood and cerebrospinal 
fluid subtentorially about the cerebel- 
lum and medulla — this indicating a 
direct medullary compression. Ven- 
tricles negative. 

Remarks. — The early marked signs 
of high medullary compression occur- 
ring so quickly following a head injury 
indicated a direct medullary com- 
pression; for this reason, no lumbar 
puncture was attempted, although now it would be performed safely 
by using the spinal mercurial manometer so that there would be no danger 
of increasing the medullary compression by a "choking" of the medulla 
in the foramen magnum; also, if such a patient was now examined, a sub- 
occipital decompression would be immediately performed rather than the 
subtemporal decompressions — which are of little or no value in relieving 
the acute direct medullary compression occurring in head injuries. It 
would have been better surgical judgment not to have performed the opera- 
tion when it was ascertained that the signs of medullary edema had already 
occurred; if this patient could have been operated upon two hours earlier, 
a recovery of life might have been obtained. 

Alcohol as a factor in increasing the mortality of brain injuries by les- 
sening the natural resistance of the patient, so that medullary edema occurs 
much more easily in these patients, was present in this case ; the mortality, 
following brain injuries in patients suffering from chronic alcoholism, is 
exceedingly high. 




Fig. 110. — Linear fracture of left petrous bone 
in a patient dying from medullary edema due 
to the high pressure of a subdural hemorrhage 
and cerebral edema. 



ACUTE BRAIN INJURIES 355 

In the presence of very high intracranial pressure as in this patient, 
although having the localizing sign of a dilated left pupil — indicating the 
paralytic effect of higher pressure over the ipsolateral left cerebral hemi- 
sphere, it is better surgical judgment to perform first, a right subtemporal 
decompression in such a patient who is right-handed, and then the decompres- 
sion over the side of the head having the signs of the higher pressure ; in this 
manner, there is less danger of severe operative damage to the more highly 
developed underlying left cerebral cortex. Naturally, in patients having 
signs of only an increased intracranial pressure and not of extreme degree, 
then the decompression would be performed over the side of the head, 
exhibiting the signs of higher intracranial pressure — in this patient, the 
left hemisphere. 

Case 78. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to subdural hemorrhage and cerebral edema. Bilateral 
decompression and drainage. Medullary edema; death. Autopsy. 

No. 789. — Daniel. Twenty-eight years. White. Single. Chauffeur. U. S. 

Admitted February 25, 1917, Polyclinic Hospital. 

Operations (February 25, 1917 — 24 hours after injury). — Bilateral 
decompression and drainage. 

Died February 25, 1917 — immediately following operations. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — While patient was walking across the street, he was 
struck by an automobile and knocked headforemost into an iron water- 
hydrant; immediate loss of consciousness; brought to the hospital in 
the automobile. 

Examination upon admission (15 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 60 ; respiration, 20 ; blood-pressure, 136. Well-developed 
and nourished; unconscious, but very restless. An extensive hematoma 
over the left parietal area extending down into left mastoid region. Profuse 
bleeding from left ear ; left mastoid ecchymosis. Pupils — pin-point, equal 
and do not react to light. Reflexes — patellar very much exaggerated, right 
greater than left ; right ankle clonus, right Babinski and a suggestive right 
Oppenheim and right Gordon reflex; abdominal reflexes absent. Fundi — 
unable to examine the fundi with the ophthalmoscope on account of the 
extreme contraction of both pupils. 

Treatment. — Expectant palliative ; careful observation. Within 1 hour, 
however, both pupils became widely dilated, right more than left, and did 
not react to light. Reflexes remained the same as at preceding examination, 
but the ophthalmoscope revealed the retinal veins markedly dilated with 
extensive retinal hemorrhages and an edematous obscuration of both optic 
disks — a papilledema of 1 diopter in swelling. Lumbar puncture — bloody 
cerebrospinal fluid under high pressure (21 mm.). The pulse had ascended 
to 92, while the respiration was irregular but deep, with a blood-pressure of 
120, and the patient was becoming more and more profoundly unconscious. 

Treatment. — In the belief that the pulse-rate of 92 was possibly due to the 
profuse hemorrhage from the left ear (120-130 drops per minute wore escap- 
ing) and that this increase of the pulse-rate was not due to an early onset of 



356 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



.. 



medullary edema, it was thought advisable to perform a left subtemporal de- 
compression immediately in the hope that this fatal complication might be 
avoided. While waiting for the operating-room to be prepared, a rontgeno- 
gram was taken, revealing an occipital fracture (Fig. 111). 

First Operation (2 hours after admission). — Left subtemporal decom- 
pression (no anesthesia being necessary) : usual vertical incision, bone re- 
moved and no complications. Dura exceedingly tense and bluish, and upon 
incising it, bloody cerebrospinal fluid spurted a distance of 3 feet, striking 
the operator in the eye; upon enlarging dural opening, the underlying 
cortex protruded and ruptured for a distance of 2 cm.; an attempt to tap the 
left lateral ventricle not successful, and as the underlying cortex was com- 

paratively " dry ' ' but 

"water-logged," and under 

i | such high tension that the 

cortex did not pulsate, a 
right subtemporal decom- 
pression was considered 
necessary. Usual closure 
with 2 drains of rubber tissue 
inserted. Temporary sterile 
gauze dressing applied. 

Second Operation (imme- 
diately following the first 
operation) . — Right subtem- 
poral decompression: usual 
vertical incision, bone re- 
moved and no complications. 
Dura very tense and upon 
incising it, bloody cerebro- 
'"**" "" r " spinal fluid spurted a 

distance of over 2 feet ; upon 
enlarging dural opening, the 
underlying cortex tended to 
protrude but did not rup- 
ture. A small amount of cerebrospinal fluid and blood escaped, but not of 
sufficient quantity to permit the cortical tension to lessen. No cortical 
hemorrhage or laceration visible — merely a "water-logged" brain. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 85 minutes. As 
the skin was being sutured, the patient suddenly became worse, pulse became 
imperceptible, respirations ceased, although the heart-beat continued for 
almost 3 minutes until the patient died — a death typical of medullary edema 
in that the heart-beat had ascended rapidly to 150 plus and the respirations 
to 40 plus, while the blood-pressure had descended to 81 before death. 

Autopsy (Doctor Weston). — Large hematoma over left temporo-parieto- 
occipital area. Wide linear fracture extended from posterior occipital pro- 
tuberance downward and forward to the left of the foramen magnum and 
then forward and to the left — tearing the left lateral sinus and then into the 
left petrous bone along its superior margin toward the sella turcica with 




Fig. 111. — Linear fracture of the right half of occipital 
bone, extending into the right petrous bone in a patient 
upon whom a bilateral decompression was performed in 
the hope that it might prevent the advance of an early medul- 
lary edema. 



ACUTE BRAIN INJURIES 357 

several lines of fracture radiating anteriorly and laterally from it. (See 
frontispiece.) Large subtentorial hemorrhage about the medulla com- 
pressing it. Small amount of subdural hemorrhage over both hemi- 
spheres. Brain tissue itself not damaged, but very much swollen and 
"water-logged." Ventricles negative. The orbital surface of both frontal 
lobes slightly contused. 

Remarks. — The question of shock in this patient was seriously considered 
as being an important factor in the condition, especially regarding the 
advisability or not of an early operation being attempted; the signs of 
a rapidly increasing pressure, however, with a blood-pressure of 136, made 
the factor of shock of almost negligible character and could not be consid- 
ered as prohibiting an attempt to improve the condition of the patient. 
However, the increase of the pulse-rate from 60 to 92, while the blood- 
pressure decreased from 136 to 120, should have indicated to us that a medul- 
lary edema had already occurred and that the prognosis was absolutely 
bad — with or without operation — and naturally, no operation should have 
been performed. 

The autopsy findings indicate such a high intracranial pressure, and 
especially such a direct compression of the medulla by subtentorial blood 
and cerebrospinal fluid, that a medullary edema seems inevitable. The 
rupture of the left sigmoid sinus is in itself sufficient cause of death in that 
when it bleeds subtentorially a direct compression of the medulla results. 

The presence of chronic alcoholism in this patient was undoubtedly a 
factor in allowing the medullary edema to occur much more easily than in a 
patient of greater resistance, and yet any patient, no matter how resistant, 
would have succumbed to an injury of this severe character. 

It would have been better judgment if a lumbar puncture with the meas- 
urement of the pressure of the cerebrospinal fluid had been made immedi- 
ately after the patient's admission to the hospital, and it is always now 
performed in similar patients ; so mild were the signs of shock at this time, 
that it could have been performed with little or no disturbance of the patient, 
and in this manner the accurate estimation of the intracranial pressure 
could have been obtained and possibly an earlier attempt to lessen the 
increased intracranial pressure would have been possible. And yet, the 
autopsy findings were of such a severe character in this particular patient 
that it is very doubtful whether any operative procedure could have 
benefited him. 

A lumbar puncture was most carefully performed upon this patient 
before operation because it was believed that the subtentorial pressure was 
very high ; although the patient was in the condition of shock, having a 
subnormal temperature and a low blood-pressure, yet the pulse was 60 — a 
clinical syndrome in these patients indicating a high direct medullary 
compression in the presence of shock. To perform a lumbar puncture, there- 
fore, and to allow the escape of cerebrospinal fluid might thus take away, 
to a greater or less degree, some of the supporting pressure beneath the 
medulla, and thus permit the medulla to be jammed down into the foramen 
magnum, producing the acute symptoms and signs of extreme medullary 
compression. This has occurred in patients having large subtentorial 



358 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tumors, but since the lumbar puncture can now be so performed that no 
fluid is withdrawn, and its pressure can be estimated without lessening to 
any appreciable extent the intraspinal pressure, therefore the danger of this 
medullary complication is practically nil. In this patient, however, the sub- 
tentorial pressure was in itself so high that the same effect upon the medulla 
was produced, in that the medulla was "choked" in the ring of the fora- 
men magnum. A suboccipital decompression should have been considered 
in this patient. 

In the operations upon these patients, especially upon the right side 
during the first operation, a ventricular puncture should always be per- 
formed in the hope that the ventricles are dilated with fluid and thus the 
cerebral tension can be immediately lessened by the withdrawal of this 
fluid; this procedure should be attempted in all cases having extreme 
intracranial pressure. The autopsy findings, however, in this patient showed 
that the ventricles had not been blocked and therefore a ventricular tapping 
would have been of no assistance. 

Case 79. — Acute severe brain injury associated with a perforating bullet 
injury of entire brain and with high intracranial pressure due to subdural, 
intracerebral and ventricular hemorrhage. Bilateral decompression and 
drainage. Death. Autopsy. 

No. 021. — Oliver. Sixty-six years. White. Married. Retired. U. S. 

Admitted August 15, 1913 — 3 hours after injury, Polyclinic Hospital. 
Referred by Doctor W. S. Pritchard. 

Operations (August 15, 1913 — 1 hour after admission). — Bilateral de- 
compression and drainage. 

Died August 16, 1913 — 12 hours after operation. 

Family history negative. 

Personal History. — Always well and strong; no alcoholism. Following 
the burning of his country home 3 years ago, patient became melancholy, 
depressed, and developed a large number of eccentricities : became very 
miserly and penurious — permitted meat to be used only once a week in the 
family in order to lessen the expense, and also prohibited the use of the 
bath-tub but once a week to save water and to prevent the "wearing-out of 
the pipes" by the running water ; the use of the toilet was also included. 

Present Illness. — Three hours ago (11 a.m.) , the patient was found in the 
bathroom shot through the head — one .32-calibre revolver bullet passing 
through the vertex of the skull transversely and the other bullet entering 
at the vertex and perforating the brain vertically downward to lodge just 
posterior to the foramen magnum. Profuse bleeding from the vertex — being 
both the wounds of entrance and of exit of one of the bullets. Unconscious ; 
brought to the hospital in the ambulance. 

Examination upon admission (3 hours after injury). — Temperature, 
99.2° ; pulse, 74; respiration, 16; blood-pressure, 152. Well-developed and 
nourished. Profoundly unconscious with stertorous irregular respiration of 
the Cheyne-Stokes type. Profuse bleeding and discharge of bloody cerebro- 
spinal fluid from the large bi-parietal wound at the vertex — 1 inches in 
width and extending above the longitudinal sinus ; small perforating dural 
wound one inch to the right of the longitudinal sinus — the entrance of the 



ACUTE BRAIN INJURIES 359 

other bullet. No definite paralyses elicited. Profuse discharge of blood and 
cerebrospinal fluid from the right ear. No powder burns or marks found. 
Pupils moderately dilated but equal, and react to light sluggishly. Reflexes 
— patellar present and equal; no ankle clonus nor Babinski ; abdominal 
reflexes present and equal. Fundi— retinal veins full and tortuous ; nasal 
halves of both optic disks and temporal margins blurred by edema— though 
no measurable swelling ascertained. Lumbar puncture — bloody cerebro- 
spinal fluid under increased pressure (approximately 19 mm.). 

Treatment.— -The presence of marked signs of high intracranial pressure 
associated with a perforating bullet injury of the brain and not associated 
with severe shock, made advisable a right subtemporal decompression and 
drainage, both for the purpose of lowering the increased intracranial pres- 
sure and thereby to prevent, if possible, a severe degree of medullary com- 
pression, but also to lessen 
the great danger of an infec- 
tive meningitis and meningo- 
encephalitis resulting from 
the passage of the bullet with 
foreign material intracrani- 
ally. The wound at the ver- 
tex was cleaned and packed 
with sterile gauze, so that 
the bleeding ceased; the 
longitudinal sinus had not 
been injured; brain tissue 
was oozing through the dural 
wound under high tension. 
An X-ray picture was taken 
while waiting for the opera- ^ ' 

+ino> -r^nm -f-n V.A nrPT^ai-Pfl Fig. 112.— Lateral rontgenogram showing the bullet wound 

Llllg iOUm IU ue JJiejJdieu of en t ran ce at the vertex and its course downward to its 

("PitT 1 ION lodgment, just posterior to the foramen magnum; the right 

V o* '' ventricle was perforated in its descent. 

Operation (1 hour after 
admission and 4 hours after injury). — Bilateral decompression (no anes- 
thesia being necessary) : First, right subtemporal decompression ; usual 
vertical incision, bone removed and no complications. Dura very tense 
and bluish and, upon incising it, bloody cerebrospinal fluid spurted to a 
height of almost 6 inches; upon enlarging the dural opening, the under- 
lying cortex tended to protrude under high intracerebral pressure, causing 
the cortex to rupture in 3 places; multiple punctate hemorrhages through- 
out the cortex giving it theS appearance almost of liver tissue. The cere- 
bral pressure remained so high that the cortex protruded through the 
dural opening, so that a left subtemporal decompression was considered 
advisable to lessen this extreme intradural pressure. Usual closure with 3 
drains of rubber tissue inserted. Temporary sterile gauze dressing applied. 

Second. — Left subtemporal decompression : usual vertical incision, bone 
removed and no complications. The underlying dura was also very bluish 
and tense, and upon incising it, a supraeortieal hemorrhagic clot of 
2 cm. in thickness was evacuated, permitting the underlying compressed 



3 6o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



cortex to rise. Numerous punctate hemorrhages throughout the cortex 
but no lacerations visible. Before the end of the operation, owing to the 
escape of much free blood and cerebrospinal fluid, the cortex pulsated 
feebly but still under tension. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 85 minutes. 

Post-operative Notes. — After the dura had been incised in the left sub- 
temporal decompression, the patient opened his eyes and appeared to be 
conscious, although no anesthetic was necessary; again immediately after 
the operation, the patient appeared to be conscious and continued so for 
four minutes, when he became unconscious, and remained so. Four hours 
after operation, the temperature suddenly increased to 104.6°, the pulse to 
130 and the respiration to 34, while the blood-pressure descended to 122; 
these signs of acute medullary edema rapidly progressed until patient died 
12 hours after operation — a death typical of acute medullary edema. 

Autopsy. — The perforating bullet 
wound passed downward through the 
right ventricle and obliquely forward 
to lodge just posterior to the foramen 
magnum; the other bullet had passed 
transversely across the vertex of the 
vault but had not penetrated the dura 
nor injured the underlying longi- 
tudinal sinus. A line of fracture ex- 
tended downward from the right 
mastoid bone obliquely forward along 
the petrous portion of the right 
temporal bone, across the sella turcica 
to a point just posterior to the left 
foramen rotundum (Fig. 113). The 
right lateral sinus had been torn by 
the fracture. No lines of fracture 
radiated from the wound of exit 
which was almost twice the size of the wounds of entrance. No extradural 
hemorrhage but a layer of subdural and supracortical hemorrhage of almost 
one-quarter of an inch in thickness — more over the left hemisphere. Exten- 
sive hemorrhagic clot in both ventricles. Much macerated brain tissue 
throughout the cerebral course of the bullet. A large amount of clotted 
blood beneath the tentorium as the result of the rupture of the right lateral 
sinus; the medulla itself was very edematous and "water-logged," being 
"jammed" downward into the foramen magnum. 

Remarks. — In such an extensive and severe brain injury as occurred in 
this patient, the prognosis, both as to recovery of life and normality, is very 
bad indeed; the only chance of recovery that this patient had lay in the 
hope of a sufficient decompression and drainage to lessen the extreme intra- 
cranial pressure, and thereby prevent the onset of an acute medullary 
edema. The autopsy findings, however, especially the rupture of the right 
lateral sinus and the perforation of the right ventricle with profuse hemor- 
rhage into both ventricles, made the recovery of this patient impossible. 




Fig. 113. — An extensive basilar fracture ex- 
tending from the right occipital bone through the 
right petrous bone and across the sella turcica 
into the left middle fossa, in a patient dying from 
an acute medullary edema following a perforat- 
ing bullet injury of the brain. 



ACUTE BRAIN INJURIES 3 6r 

All penetrating gunshot injuries of the skull, where the dura has been 
entered, should be treated as brain injuries associated with a fracture of 
the skull and with signs of increased intracranial pressure, as all of these 
patients have both an acute cerebral edema with more or less intradural 
hemorrhage ; therefore, the treatment should be directed toward a lessening 
of this increased intracranial pressure by means of a subtemporal decompres- 
sion and drainage, and if necessary a bilateral decompression and drainage ; 
naturally the shock must be survived first to permit any operative procedure. 

It was very interesting in this patient to observe the return to conscious- 
ness following the opening of the dura in the left subtemporal decompression, 
and thereby indicating a marked lessening of the high intracranial pressure ; 
this relief was only temporary owing to the continued bleeding into the ven- 
tricles and subtentorially about the medulla. It is extremely rare for 
patients to survive longer than 12 hours following a hemorrhage into the 
ventricle. The slight impairment of the reflexes of this patient upon his 
admission to the hospital is very surprising and it merely emphasizes 
the necessity of considering the entire clinical picture rather than indi- 
vidual signs. 

The line of fracture at the base passing through the right lateral sinus, 
the right petrous bone and across the sella turcica following a gunshot injury 
of the vertex with no lines of fracture extending downward from the vertex, 
indicates that this basal fracture was the result either of the explosive effect 
of the bullet injury (which is very doubtful and especially of this type) or 
that the patient in falling had struck hisi head violently against the floor or 
other solid object and the basal fracture resulted from it; this is the more 
probable explanation. If this complication had not occurred, the chances 
of the patient for recovery would have been greatly improved, although 
the ventricular hemorrhage is almost always a fatal complication. 

Acute Severe Brain Injuries, with and Without a Fracture of the 
Skull, and Complicated by Meningitis. Death; Autopsy. 

The complication of a purulent meningitis and meningo-encephalitis in 
patients having brain injuries usually results from an infection extending 
through the line of fracture by means of the nose, naso-pharynx or the ears 
in basal fractures, and in fractures of the vault in the presence of an over 
lying infected laceration or even contusion of the scalp, and especially if the 
adjacent dura has been torn; infected lacerations and hematomata of the 
scalp, even in the absence of an underlying fracture of the vault, may be 
a sufficient source of infection to extend intracranially by means of the 
diploetic veins and thus a purulent meningitis eventually appears ; this 
complication occurs only too frequently following a cellulitis of the scalp — 
a most dangerous complication of cranial injuries. 

In those patients having brain injuries associated with a high intra- 
cranial pressure sufficient to necessitate the operation of decompression and 
drainage, the complication of meningitis may not appear until five or six 
days following the decompression, and it is then always a question whether 
the meningitis has resulted from an inexcusable error in the operative 
technic or from improper treatment of the tissues adjacent to the line of 



362 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

fracture into the nose, ears or the overlying scalp. The complication of 
meningitis, however, rarely occurs in these latter patients following early 
decompression and this is undoubtedly due to the early lessening of the 
increased intracranial pressure, so that these patients not only are less 
comatose and their general condition more resistant to infection, but the 
local tissues themselves have a more normal resistance to an infective process 
on account of their more normal circulation, whereas in stuporous and even 
unconscious patients without operation their general condition of resistance 
is quickly lowered and the local tissues become congested, boggy and ede- 
matous from the venous stasis resulting from the increased intracranial pres- 
sure and therefore less resistant to an infective process ; besides, tissues under 
pressure are themselves not so capable of resisting an infective process as 
they are under the normal conditions of tension and circulation. This 
explanation may thus account for the greater freedom from an infective 
meningitis of patients whose increased intracranial pressure has been lowered 
early by the operation of decompression and drainage. 

If. however, the early signs of an infective meningitis, and especially 
of the localized type, appear in a patient upon whom an operation has been 
performed or not. then an immediate subtemporal decompression and 
drainage should be advised in the hope that an early lessening of the in- 
creased intracranial pressure and the associated drainage would be suffi- 
cient to afford the patient a possible chance of recovery. No patient of this 
type, however, should be operated upon in whom the cerebrospinal fluid at 
lumbar puncture contains the bacterial organism itself, since this positive 
finding indicates the diffuseness of the infective process and the condition 
is therefore practically hopeless. If the signs of meningitis are recognized 
early, then the cerebrospinal fluid at lumbar puncture is frequently clear 
or only slightly turbid with an increased cell count due to the meningeal 
irritation and no bacteria can be found — these are the patients upon whom 
the operation of subtemporal decompression and drainage and even a sub- 
occipital decompression and drainage combined with a laminectomy and 
drainage may offer a chance of recovery ; it is only a chance, but it is worth 
taking as the risk is negligible compared with the condition itself, and 
although it is rare for the patient to recover, yet there are cases reported. 
I have only two patients that recovered following the operation of decom- 
pression and drainage out of a series of 14 who had all the signs of a purulent 
meningitis confirmed either at operation or at autopsy ; neither of these two 
patients, however, exhibited the bacterial organism in the cerebrospinal 
fluid at lumbar puncture. 

Acute severe brain injuries eissociate'cl with et fracture of the skull; menin- 
gitis. Death; autopsy. 

A. No marked signs of intracranial pressure and therefore no operation 
having teen performed. 

Case 80. — Acute severe brain injury associated with a subdural hemor- 
rhage and a fracture of the skull, but no signs of high intracranial pressure. 
No operation. Meningitis ; death. Autopsy. 

No. 145. — Agnes. Thirtv-one vears. "White. Married. Housework. U. S. 



ACUTE BRAIN INJURIES 363 

Admitted May 28, 1914, Polyclinic Hospital. Referred by Doctor 
John A. Bo dine. 

Died June 4, 1914 — 6 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While hanging out clothes from a fire-escape, patient 
fell a distance of 12 feet upon the stone pavement below ; immediate loss of 
consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 97.6° ; pulse, 82 ; respiration, 20 ; blood-pressure, 134. Semiconscious- 
ness and in shock. Extensive laceration over left occipital area down to 
bone ; careful probing did not reveal an underlying fracture. No bleeding 
from nose, mouth or ears ; no mastoid ecchymoses. Pupils equal and 
react normally. Reflexes slightly depressed but otherwise negative. 
Fundi negative. 

Treatment. — Expectant palliative; laceration of scalp widely shaved, 
cleaned and loosely sutured with one drain inserted. Careful observation in- 
stituted, but it was not considered that the patient was seriously injured in- 
tracranially. Within a few hours, the signs of shock disappeared and the 
general condition of the patient improved so that an excellent prognosis was 
given. Twenty-four hours after admission, patient complained of some head- 
ache and backache and an impairment of the left ear ; otoscopic examination 
revealed a bluish discoloration of the left tympanic membrane, and it was 
then for the first time that a fracture of the skull was suspected, and there 
were present no signs of an increased intracranial pressure. (The lesion of 
the left middle ear was demonstrated by the sound of the tuning fork being 
always referred to the left ear — Weber 's test, and the bone conduction of the 
left ear being always greater than air conduction — Rinne's test.) With the 
exception of impairment of hearing of the left ear, patient seemed to be 
making an excellent recovery until June 3 (5 days after injury), when the 
patient complained of severe headache, was nauseated for several hours and 
finally vomited; the temperature was 100.2°, pulse 80, respiration 20, blood- 
pressure 136 ; the physical examination was negative except that the oph- 
thalmoscope revealed enlarged retinal veins but no blurring of the details 
of either optic disk. This condition continued until 18 hours later, when the 
patient could not be aroused by the nurse and the following examina- 
tion was made : 

Examination (6 days after injury). — Temperature, 103.8°; pulse, 120; 
respiration, 32; blood-pressure, 140. Profound unconsciousness. Slight stiff- 
ness of the neck but no Kernig reflex. No ocular paralyses nor convulsions. 
Pupils slightly enlarged but equal and react to light sluggishly. Reflexes — 
patellar active but equal ; no ankle clonus nor Babinski ; abdominal reflexes 
cannot be elicited. Fundi — retinal veins enlarged; no blurring of the optic 
disks. At this stage of the examination, the respiration suddenly became 
irregular and then ceased; artificial respiration and pulmotor continued 
life for 4 hours — pulse rising to 160 plus and finally became imperceptible: 
patient died 6 days after injury. 

Autopsy (Doctor O. IT. Schultze). — A line of fracture of the bursting 



364 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






type began in left occipital bone about 2 cm. below the lacerated area of 
the scalp and extended downward and forward into and along the crest of 
the left petrous bone to the sella turcica where it stopped ; another line of 
fracture extended through the left orbital plate and the left greater wing 
of the sphenoid bone — either fracture line being possibly the source of the 
infection (Fig. 114). Subperiosteal hemorrhages were situated over both 
orbital plates. Covering the entire left hemisphere and the upper portion of 
the right hemisphere was a thin creamy purulent exudate (bacteriological 
report (Doctor Jeffries)— "staphylococcus") ;much thick creamy pus in the 
base, especially in the middle and posterior fossae. Cortical laceration and thin 
supracortical hemorrhage over right frontal lobe and tip of right temporo- 

sphenoidal lobe. Small cortical lacer- 
ations over the posterior portion of 
left cerebellar lobe — underlying the 
point of contact. Ventricles negative. 
Remarks. — This is a most instruc- 
tive case: if a meningitis had not 
occurred and the patient had recov- 
ered (as was our belief on the third 
day after admission), the diagnosis 
would have been a "possible fracture 
of the skull" or even a "severe con- 
cussion with laceration of the scalp." 
No doubt many brain injuries, with or 
without fractures of the skull, are 
thus diagnosed, and it is only when 
complications occur necessitating an 
operation, or if death should occur and 
an autopsy is performed, then the true 
condition is ascertained. A rontgeno- 
gram should have been taken of this 
patient, and it is possible that the 
occipital fracture would have been 
located by taking the pictures in different planes and angles ; this would have 
been important not so much from the standpoint of treatment as to whether 
a cranial operation should be performed or not, but to warn the medical 
attendant that the cranial injury may be of greater severity than a mere 
"bump" upon the head and the so-called "concussion" — a much over- 
worked term and applied much too frequently. Then again, a lumbar punc- 
ture should have been performed as soon as the patient had recovered from 
the signs of shock ; if blood had been found in the cerebrospinal fluid, even 
in the absence of an increased intracranial pressure, it would have at least 
informed us that the intracranial condition was one of greater moment than 
a mere "concussion." Besides, a lumbar puncture should have been per- 
formed surely on the fifth day after admission, when the patient complained 
of severe headaches and even vomited, and especially when the temperature 
had risen from 99° to 100.2° ; the fact that the ophthalmoscopic examina- 




Fig. 114. — Wide linear fractures of the left 
base — the posterior fracture of the left petrous 
bone being the probable pathway of infection 
and resulting purulent meningitis in this patient. 



ACUTE BRAIN INJURIES 365 

tion was practically negative should not have lulled us into the feeling that 
the condition was possibly of intestinal origin. From the standpoint of not 
having had an X-ray picture taken, and especially the neglect to have a 
lumbar puncture performed — these two oversights and mistakes are strongly 
reprehensible and should not be permitted to occur. 

The source of the purulent meningitis was undoubtedly through the left 
middle ear (even though the left tympanic membrane was intact), although 
the laceration of the scalp being in close proximity to the fracture of the 
occipital bone might have been a possible source of the infection ; the lacera- 
tion of the scalp, however, was ' ' clean, ' ' and the dura underlying the occipital 
fracture was not involved by the meningitis. 

The autopsy findings of cortical lacerations of the anterior surface of the 
right frontal lobe and of the right temporo-sphenoidal lobe would indicate 
cerebral trauma au contre-coup, whereas the small laceration of the posterior 
portion of the left cerebellar lobe immediately underlying the site of the 
cranial injury — the area of contact, would be the result of the direct local in- 
jury. These cortical lacerations of comparatively silent areas of the brain are 
relatively unimportant, unless the resulting hemorrhage and cerebral edema 
are of such large amount that the intracranial pressure is greatly increased 
and therefore necessitating the operation of cranial decompression and 
drainage. These latent cortical lesions are undoubtedly of much greater 
frequency than is usually realized, and it is only by careful autopsy examina- 
tions that many of them are even suspected. 

It would seem from the autopsy findings that the meningitis in this 
patient had resulted from an extension of infection through the left middle 
ear into the subdural spaces ; the onset was so slow and insidious that its 
presence was not suspected until the process had become so diffused through- 
out the cerebrospinal canal that there was practically no chance for the 
patient to recover by any known method of treatment. At the time, the 
advisability of performing an unilateral, and better, a bilateral decom- 
pression and drainage, and even a high laminectomy with drainage was 
considered, but the general condition of the patient became so weakened 
that even this possible means of treatment was not used ; no matter what the 
treatment, operative or not, the end-result is the same in practically all of 
these patients — once bacteria are found in the cerebrospinal fluid at lumbar 
puncture following a cranial meningitis. 

This patient illustrates the advisability of repeated lumbar punctures 
if the condition is not improving as rapidly as should be expected ; especially 
is this so in the presence of a fracture which opens into the ears, nose or 
pharyngeal cavities, and particularly if the fracture underlies a laceration 
of the scalp; the danger of the formation of single or multiple cerebral 
abscesses in these patients developing a localized meningitis is very great 
indeed. The absence of a purulent discharge from the left ear as a fore- 
runner of the infective process extending inward through the line of frac- 
ture is rather unusual; it is possibly unfortunate that a blockage occurred 
at the intact left tympanic membrane in this patient — thus facilitating 
the extension of the infection inward by not permitting free drainage. It 
is also unusual that there were no local irritative si<rns of the left cor- 



366 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tical involvement — usually recognized by convulsive seizures; greater 
reliance, however, should be placed upon the cell count of repeated daily 
lumbar punctures — the most accurate method of anticipating menin- 
geal involvement. 

B. Signs of high intracranial pressure and therefore the operation of 
cranial decompression having been performed. 

Case 81. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to subdural hemorrhage; fracture of the left vault 
and base. Left subtemporal decompression and drainage. Meningitis. 
Death. Autopsy. 

No. 103. — Joseph. Fifty years. Colored. Married. Coachman. U. S. 

Admitted January 18, 1914, Polyclinic Hospital. Referred by Doctor 
J. P. Grant. 

Operation (January 18, 1914 — 6 hours after injury). — Left subtem- 
poral decompression and drainage. 

Died February 11, 1914 — 23 days after injury and operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While driving his carriage, patient collided with a pil- 
lar of the elevated railroad and was hurled headlong against the stone 
curbing; immediate loss of consciousness; brought to the hospital in 
the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 99.2° ; pulse, 62 ; respiration, 16 ; blood-pressure, 168. Unconscious, 
but can be aroused with difficulty ; no alcoholism. Abrasion of left side of 
face, which is very much swollen and ecchymosed. No bleeding from nose, 
mouth or ears. Pupils moderately enlarged but react normally. Reflexes — 
patellar exaggerated — right more than left ; no ankle clonus but right Babin- 
ski : abdominal reflexes absent. Fundi — retinal veins enlarged ; nasal mar- 
gins of both optic disks blurred, left possibly more than right. 

Treatment. — Expectant palliative. In spite of this treatment, the signs 
of an increasing intracranial pressure became more marked — the pulse 
descended to 54 and the respiration to 14 and of the irregular Cheyne- 
Stokes character, while the blood-pressure increased to 170 ; one hour after 
admission, patient had typical "projectile" vomiting — without nausea, he 
would open his mouth and strike the wall, a distance of three feet away; 
his unconsciousness became more profound until the following examina- 
tion was made : 

Examination (4 hours after admission). — Temperature, 100.8°; pulse, 
52 ; respiration, 14 ; blood-pressure, 170. Profound unconsciousness and 
cannot be aroused. Large hematoma over left side of face ; no fracture of 
the jaw can be ascertained. Pupils — left larger than right and reacts to light 
sluggishly. Reflexes — patellar markedly exaggerated, right very much 
greater than left with right patellar clonus; right ankle clonus and right 
Babinski ; right abdominal reflex absent. Fundi — retinal veins dilated ; 
entire left optic disk blurred by edema but no measurable swelling, while 
nasal half and temporal margin of right optic disk obscured. Lumbar punc- 
ture — bloody cerebrospinal fluid under high pressure (approximately 20 



ACUTE BRAIN INJURIES 367 

mm. ) . The spasticity of right arm and right leg had now developed into a 
definite weakness of the entire right side of the body (as well as could be 
elicited in a patient so profoundly unconscious). 

Treatment. — A left subtemporal decompression was immediately advised 
to prevent a greater medullary compression and thereby avoid the danger of 
the onset of an acute medullary edema. 

Operation (5 hours after admission). — Left subtemporal decompression 
(no anesthesia being necessary) : usual vertical incision, bone removed and 
no complications ; bone itself unusually thick and like ivory. Dura under 
high tension, and upon incising it, blood-tinged cerebrospinal fluid spurted 
a distance of 12 inches; upon enlarging the dural opening, much bloody 
cerebrospinal fluid escaped, exposing a very "wet" edematous cortex which 
soon pulsated normally. No cortical hemorrhages or lacerations visible. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 50 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery — 
becoming conscious 30 hours after operation, and although mildly irrational 
for 2 days, he seemed on the road to an excellent recovery ; all sutures were 
removed'on the sixth day post-operative. Eight days after operation, patient 
developed a temperature of 104°, and then the signs of an infection of the 
hematoma over the left side of the face appeared in that it became unusually 
tender, painful and feverish ; no fluctuation obtained, however ; it was incised 
and carefully treated by Doctor John P. Grant and by Doctor J. A. Robertson 
— the culture showing pure growth of a short-chained streptococcus ; in spite 
of this vigorous treatment, the patient developed the signs of meningeal 
irritation — the operative decompression area bulged, temperature ascended 
to 107° and the patient eventually died from the signs of a typical menin- 
gitis on the twenty-third day after injury and operation ; a lumbar puncture 
had obtained a cloudy cerebrospinal fluid — a "pure growth of a short- 
chained streptococcus. ' ' 

Autopsy. — The 2 incisions of the hematoma over left side of face did 
not contain any frank pus. Decompression wound healed perfectly. Frac- 
ture of skull extending from the anterior margin of decompression opening* 
downward into left anterior fossa of the skull — a distance of 4 inches (Fig. 
115). No extradural hemorrhage, but a thin layer of subarachnoid hemor- 
rhage over entire left frontal lobe extending backward to the left Rolandic 
fissure. Thick plastic exudate over the entire left temporo-sphenoidal lobe ; 
very thick creamy-yellow pus with foul odor at the base of operative field and 
in the middle fossa, where there were almost 6 ounces of it. The infection was 
limited to left side of brain — the right hemisphere being negative. A probe 
could be passed from temporal muscle of operative field downward into 
infected area of hematoma beneath left zygomatic arch — a very possible 
means of the extension of the infection of the hematoma. (Cultures 
of this intracranial pus showed both streptococci and staphylococci.) Ven- 
tricles negative. 

Remarks. — In the presence of skull fractures in close proximity to exten- 
sive hematomata, either of the scalp or of the adjacent tissues of the face 
and neck, it is always wiser and safer to incise the hematoma early under 
aseptic conditions, so that future infection of the hematoma is Lessened 



368 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



fR«lCTURt 



and the great danger of an infective extension from the hematoma through 
the fracture of the skull intracranially is thus avoided. This precaution is 
particularly advisable in cases of hematoma of the scalp having a fracture 
of the underlying bone ; large hematomata are particularly susceptible to 
infections through the skin, especially when they are under tension, and 
if they do become infected, then the danger of this infective process extend- 
ing through the underlying fracture is very great indeed. Undoubtedly 
this patient would have recovered if this complication could have been antici- 
pated; at no time, however, was there any fluctuation of the hematoma to 
be obtained — merely a boggy edema of the tissues and therefore no incision 
had been considered advisable. During the past 2 years, all hematomata of 
the scalp were incised early under aseptic precautions whenever there was 
an adjacent fracture of the skull, and during this period of 2 years a menin- 
gitis complicating the recovery has not 
yet occurred. The autopsy findings 
demonstrate the cause of the weakness 
of the right side of the body in that 
a layer of subarachnoid hemorrhage 
was found over the entire left cortical 
hemisphere anterior to the fissure of 
Rolando. Why convulsions of the 
localizing type did not occur cannot 
be explained, unless the general intra- 
cranial pressure was so high as to 
inhibit the irritative effect of the cor- 
tical lesion. 

It is again unfortunate in this 
patient that a lumbar puncture was 
not performed upon his admission to 
the hospital as it is possible that a defi- 
nite increase of the intracranial pres- 
sure would have been ascertained then 
and an earlier operative relief would 
have been afforded: the absence of shock would have made this a safe 
procedure. However, with the later operation the patient made an excel- 
lent recovery, but that does not always occur following these delayed opera- 
tions, for it is then frequently too late for the patient to recover. 

Case 82. — Acute severe brain injury associated with high intracranial 
pressure due to subdural hemorrhage and cerebral edema ; fracture of the 
vault. Left subtemporal decompression and drainage. Meningitis. 
Death. Autopsy. 

No. 115. — Frederic. Thirteen years. White. School. U. S. 
Admitted January 28, 1911, Polyclinic Hospital. Referred by Doctor 
A. S. Morrow. 

Operation (January 30. 1911 — 10 hours after injury). — Left subtem- 
poral decompression and drainage. 

Died February 9. 1911 — 10 days after operation and 12 days after injury. 




Fig. 115. — Wide linear fracture of left anterior 
fossa of the base of the skull — a very probable 
source of infection and resulting meningitis in 
this patient — either from the infected hematoma 
of the left side of face or through the cribriform 
nlate of the ethmoid bone. 



ACUTE BRAIN INJURIES 369 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in a school yard, the patient fell a dis- 
tance of nine feet, striking his head upon the stone pavement; no immediate 
loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (1 hour after injury). — Temperature, 
97.6°; pulse, 96; respiration, 28; blood-pressure, 108. Semiconscious and 
in severe shock. Large hematoma over left side of head ; definite fluctuation. 
No bleeding from nose, mouth or ears. Pupils slightly enlarged but react 
normally. Reflexes — patellar active but equal ; no ankle clonus but right 
Babinski; abdominal reflexes absent. Fundi negative. 

Treatment. — Expectant palliative; vigorous shock measures instituted. 
Within 30 minutes, although the pulse had ascended to 120, the temperature 
had increased to 99° and the blood-pressure to 120 so that it could be said 
that the general condition had improved. Patient remained in a semicon- 
scious condition for 36 hours, when the signs of an increasing intracranial 
pressure appeared. 

Examination (37 hours after admission). — Temperature, 100.6°; pulse, 
80 ; respiration, 18 ; blood-pressure, 118. Patient has become more stuporous 
and when aroused is irrational; holds hands to head as though in pain. 
Hematoma over the left side of head very tense. Pupils — left larger than 
right and does not react to light. Reflexes : patellar — right more active than 
left ; right exhaustible ankle clonus and right Babinski ; abdominal reflexes 
present, right possibly less active than left. Fundi — retinal veins enlarged ; 
nasal halves of both optic disks obscured by edema — temporal margins, 
however, clear. Lumbar puncture — blood-tinged cerebrospinal fluid under 
high pressure (approximately 17 mm.). X-ray report (Doctor A. J. 
Quimby) — "two lines of fracture extending irregularly through squamous 
portion of left temporal bone." 

Treatment. — An immediate left subtemporal decompression advised to 
lessen the increasing intracranial pressure. 

Operation (39 hours after admission). — Left subtemporal decompres- 
sion ; usual vertical incision, bone removed and no complications ; much free 
blood and several clots in the temporal muscle itself beneath the temporal 
fascia and therefore a fracture of the underlying bone was to be expected ; 2 
irregular lines of fracture extended obliquely through the underlying squa- 
mous bone; much free blood escaped through the lines of fracture, though no 
definite extradural hemorrhage was ascertained upon removing the bone. 
Dura very tense and upon incising it, blood-tinged cerebrospinal fluid 
spurted a distance of 2 inches for a period of 5 seconds ; upon enlarging the 
dural opening, much bloody cerebrospinal fluid escaped, allowing the under- 
lying bulging cortex to recede and to pulsate normally at the end of the 
operation. No cortical hemorrhage or laceration visible — merely a very 
"wet" edematous brain. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 40 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery ; 
within 12 hours, the pulse ascended to 80 and remained at this level ; complete 
return of consciousness and the patient merely complained o\' a dull throb- 
24 



370 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



bing headache. At the first dressing — 44 hours after operation — one drop 
of pus (staphylococcus upon culture) was found. On February 5 — 6 days 
after operation — the temperature suddenly ascended to 103°, and upon re- 
moving the sutures, a small amount of cerebrospinal fluid escaped mingled 
with pus (staphylococcus) ; pulse ascended to 138, neck became rigid and a 
positive Kernig reflex was elicited ; the cerebrospinal fluid at lumbar puncture 
Was cloudy (staphylococcus also upon culture). Patient now became pro- 
gressively worse and died from a diffuse meningitis — 10 days after operation 
and 12 days after injury. 

Autopsy. — Two small lines of fracture extended from the anterior edge of 
left decompression opening forward and downward into the anterior and 
middle fossae of the base of the skull (Fig. 116) . Thick creamy pus (staphy- 
lococcus upon culture) covered not only the left hemisphere but also the 

right hemisphere and extended into 
the subtentorial fossa ; the decompres- 
sion wound was thoroughly saturated 
with this pus. Several small pieces 
of bone wax which had been used to 
control the bleeding from the edges 
of the bony opening were found in 
excess. Bacteriological examination 
of the bone wax used in the operating- 
room was now made and showed the 
presence of staphylococci, and thus 
indicating the mode of infection. 
(Through a mistake, this bone wax 
had been considered sterile, so that it 
had not been boiled before the opera- 
tion and therefore it was undoubtedly 
the cause of infection and death of 
this patient; this inexcusable error 
should not have been permitted to 
occur and it is one of those unfortunate mistakes occurring* only too fre- 
quently in a large hospital but it is not likely to be repeated. ) 

Remarks. — If no cause for the infecton in this case had been ascertained 
at autopsy, such as the bone wax, the source of infection would have 
undoubtedly been considered as due to an infection of the hematoma of the 
scalp overlying the lines of fracture ; in this patient, however, the hematoma 
seemed to be subpericranial and therefore the danger of its becoming infected 
from the scalp was not so much to be feared — unless the overlying tissues were 
severely contused or lacerated. 

It is interesting in this youthful patient of 13 years of age to note that 
the high intracranial pressure as revealed by the ophthalmoscope and the 
lumbar puncture could not cause clinically the marked signs of a similar 
high intracranial pressure in adults, and this clinical syndrome is character- 
istic in children in whom it is rare to have a pulse-rate lowered below 60 
and a respiration-rate below 16, even in the presence of severe intracranial 
pressure and medullary compression of high degree. Children are thus 




Fig. 116. — Two linear fractures of the left 
middle and anterior fossae in a patient dying from 
a purulent meningitis — an infection resulting from 
a lack of surgical asepsis in the use of non-sterile 
bone wax. 



ACUTE BRAIN INJURIES 371 

enabled to withstand the effects of high intracranial pressure much better 
than adults, and for this reason the operation of cranial decompression is 
less urgent in the majority of these youthful patients, because the onset of 
an acute medullary edema is not so much to be feared ; besides, their general 
absorptive ability "to take care of" an increased intracranial pressure due 
to subdural blood and cerebral edema is much greater than that of adults. 
The condition of shock, however, is apparently of greater significance in 
children than in adults, so that the most vigorous shock measures should be 
instituted as early as possible and thus enhance their chances of recovery. 

The importance of having an autopsy performed upon this patient cannot 
be overestimated in that the cause of death was accurately ascertained as 
being due to a careless oversight — one of ignorance, and thus future patients 
were spared this unnecessary risk. The cause of death should be ascer- 
tained by autopsy of each patient who dies, and it is only fair to future 
patients that these causes, if avoidable, should be naturally eliminated. Per- 
mission in writing for autopsy should be obtained before operation in each 
patient — from the nearest relative, and in this manner "mistakes" should 
not occur more than once. 

A recovery of life of this patient might have been obtained if, as soon as 
the appearance of a local infection of the wound occurred, a small drainage 
incision had been made, and if necessary, the entire wound reopened and 
excellent drainage afforded — similar to the treatment of an early localized 
meningitis following otitic disease for which an ipsolateral decompression 
and drainage is performed and with excellent results in the early cases ; 
during the past year this has been possible in several patients. 

Case 83. — Acute severe brain injury associated with signs of high intra- 
cranial pressure due to subdural hemorrhage and cerebral edema. Eight 
subtemporal decompression and drainage. Meningitis; left subtemporal 
decompression. Death. Autopsy. 

No. 671. — Charles. Thirty-five years. White. Married. Porter. Scotland. 

Admitted September 1, 1916, Polyclinic Hospital. 

Operations, 1st (September 1, 1916 — 8 hours after injury). — Right sub- 
temporal decompression and drainage. 2nd (September 20, 1916 — 19 days 
after first operation). — Left subtemporal decompression and drainage. 

Died September 22, 1916 — 21 days after admission and 2 days after 
the second operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While standing upon some stone steps, the patient 
slipped and fell a distance of 7 feet, striking his head against the stone 
pavement ; immediate loss of consciousness ; brought to the hospital in 
the ambulance. 

Examination upon admission (45 minutes after injury ). — Tempera- 
ture, 98° ; pulse, 120 ; respiration, 28 ; blood-pressure, 122. Unconscious and 
in severe shock. Contusion of scalp over the occipital protuberance and ver- 
tex of skull. No bleeding from nose, mouth or ears ; no mastoid ecchymoses. 
Pupils equally dilated and do not react to light. Reflexes all absent, except 
slight corneal reflex. Fundi negative. 



372 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Treatment. — Expectant palliative; vigorous shock measures instituted. 
Within 2 hours after admission, the general condition of the patient mark- 
edly improved — the temperature rose to 99.4°, while the pulse decreased to 
82 and the respiration to 18, and the blood-pressure ascended to 138 ; 3 hours 
after admission, both plantar ueflexes returned. Within the next 3 hours, 
however, the signs of an increasing intracranial pressure appeared more and 
more marked. 

Examination (6 hours after admission). — Temperature, 99.8° ; pulse, 48 • 
respiration, 14 ; blood-pressure, 140. Semiconscious and restless. Bogginess 
over right temporal area with slight right mastoid ecchymosis. Pupils 
equal and react normally. Reflexes — patellar active but equal ; slight double 
exhaustible ankle clonus and a double suggestive Babinski; abdominal re- 
flexes present and equal. Fundi — retinal veins enlarged; nasal halves of 
both optic disks blurred by edema. Lumbar puncture — bloody cerebrospinal 
fluid under high pressure (approximately 19 mm.). 

Treatment. — Owing to the signs of high intracranial pressure, as indi- 
cated by the marked lowering of the pulse- and respiration-rates and by the 
ophthalmoscopic and lumbar puncture examinations, a right subtemporal 
decompression was advised — the patient being right-handed and there being 
no localizing signs of a greater intracranial pressure over one hemisphere 
than the other. 

First Operation (7 hours after admission). — Right subtemporal decom- 
pression : usual vertical incision, bone removed and no complications ; much 
free blood in temporal muscle beneath the temporal fascia and therefore 
upon retracting the muscle, a fracture of the underlying squamous bone 
was exposed — slightly depressed. Large extradural hemorrhage evacuated, 
revealing a tense underlying dura, especially in the upper portion of the field. 
Upon incising the dura, bloody cerebrospinal fluid spurted a distance of 
3 inches, revealing a very "wet," edematous cortex with one laceration of 
about 2 cm. in length in the upper temporal convolution. Small layer of 
subarachnoid and possibly cortical hemorrhage had occurred over the middle 
temporal convolution. Much free subdural , blood and cerebrospinal fluid 
escaped during the operation, permitting the protruding cortex to recede 
and to pulsate at the end of the operation. Usual closure with 2 drains of 
rubber tissue inserted. Duration, 50 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery in 
that he became conscious and rational within 2 days, pulse ascended to 66 
and the respiration to 18, while the signs of an increased intracranial 
pressure became less marked. Decompression area continued to bulge 
tensely and the patient complained of persistent daily headaches. Nineteen 
days after operation, patient had a convulsion beginning in the right arm 
and extending to the right leg and face and then merged into a general 
convulsion ; the following examination was now made : 

Examination (19 days after admission and operation).— Temperature, 
103.2°; pulse, 96; respiration, 26; blood-pressure, 148. Decompression 
wound bulging and does not pulsate. Pupils both contracted and do not 
react to light. Reflexes — patellar very much exaggerated, right possibly 
more than left ; no ankle clonus nor Babinski : abdominal reflexes could not 



ACUTE BRAIN INJURIES 373 

be obtained. Fundi — retinal veins dilated ; double papilledema of one diop- 
ter swelling — entire retinae being congested and suffused. Lumbar puncture 
— slightly turbid cerebrospinal fluid under high pressure (approximately 
17 mm.) ; bacteriological examination (Doctor Jeffries) — "large number of 
leucocytes but no bacteria. ' ' 

Treatment. — In the presence of a high intracranial pressure and a large 
number of leucocytes but no bacteria in the cerebrospinal fluid, it was con- 
sidered advisable to perform a left subtemporal decompression and drain- 
age in the hope that the meningitis might remain localized and thus the 
patient be given a chance of recovery. 

Second Operation (19 days after first operation and injury). — Left sub- 
temporal decompression and drainage : usual vertical incision, bone removed 
and no complications; about one inch above the posterior base of the left 
zygomatic process was a bony enlargement of the squamous bone and upon 
rongeuring into it a cavity filled with, a cheesy deposit was removed (pos- 
sibly an isolated zygomatic cell of the mastoid and of the size almost of a lima 
bean) . Dura very tense and upon incising it, slightly straw-colored cerebro- 
spinal fluid spurted a distance of 3 inches, and upon enlarging the dural 
opening a very ' ' wet, ' ' edematous cortex was exposed. In the sulci about the 
vessels was a whitish exudate beneath the arachnoid but no free pus observed. 
Cortex tended to protrude but did not rupture, owing to the rapid escape of 
a large amount of cerebrospinal fluid. Usual closure with 2 drains of 
rubber tissue inserted. It was decided to explore the first decompression 
incision and upon doing so much free pus was found beneath the temporal 
fascia among the fibres of the temporal muscle ; 2 drains of rubber tissue 
inserted. (Bacteriological report (Doctor Jeffries) — "staphylococci.") 
Duration, 1 hour. 

Post-operative Notes. — Much yellowish pus drained from the first opera- 
tive incision and after 12 hours pus appeared in the drainage from the 
second decompression. Patient's condition rapidly became worse — rigidity 
of the neck occurring within 12 hours after operation, simultaneous with the 
appearance of a double Kernig reflex, while the temperature ascended to 
107° and the patient died — 40 hours after the second operation and 21 days 
after injury. 

Autopsy. — A linear fracture extended downward from the right decom- 
pression opening into the middle fossa, but did not reach the sella turcica 
(Fig. 117). Diffuse subdural meningitis and a layer of creamy pus was 
found over the entire brain — more over the right hemisphere, and also in the 
ventricles. No gross hemorrhage ascertained. 

Remarks. — The infection causing the meningitis of this patient undoubt- 
edly occurred at the time of the first operation and it is naturally inexcusable. 
It is interesting to note the long period of incubation necessary for a diffuse 
meningitis to occur, and I believe this is due to the fact that the increased 
intracranial pressure had been so lessened by the decompressed opening 
that the underlying tissues were therefore not under high pressure and thus 
their resistance to the infection was all the greater. It is unfortunate that 
the true condition of the localized meningitis beneath the site of the first 
operation could not have been ascertained earlier, so that adequate drainage 



374 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



could have been effected and thus the localized meningitis be satisfactorily 
drained with the ultimate recovery of the patient; the clinical signs, how- 
ever, of a meningitis occurred so suddenly ' ' out of a clear sky, " as it were, 
that it was then too late for satisfactory drainage to be instituted. 

The second operation of left subtemporal decompression and drainage 
was advised chiefly from the fact that the bacteriological report of the 
cerebrospinal fluid was negative for bacteria — only the presence of leuco- 
cytes being demonstrated ; if bacteria had been found at lumbar puncture, 
then not even a decompression would have been attempted, for it would have 
been realized that the meningitis was therefore an extensive and a diffuse 
process and beyond satisfactory drainage by operation. Patients, however, 
having merely a meningeal irritation or a localized meningitis and whose 
cerebrospinal fluid at lumbar puncture does not contain bacteria (even 

though turbid and cloudy, which may 
be clue to aggregations of leucocytes) 
— these patients should be given the 
chance of recovery by means of a uni- 
lateral and, if necessary, a bilateral 
subtemporal decompression and 
drainage ; this is particularly true fol- 
lowing brain injuries and the men- 
ingeal complications of middle ear and 
mastoid disease. 

The marked contraction of both 
pupils and their non-reaction to light 
at the examination just before the sec- 
ond operation indicated the cortical 
irritation due to the meningeal exu- 
date and the meningo-encephalitis ; as 
this supracortical pressure increased, 
then the irritative effect would be sub- 
merged by the paralytic effect of high 
supracortical pressure, and thus the pupils would become dilated and like- 
wise non-reacting to light. This latter stage of pupillary dilatation must not 
be confused with that dilatation which so frequently occurs immediately 
following the cranial injury — that is, the pupillary dilatation due to the 
severe shock of the injury ; naturally, the other signs of shock are present, 
particularly the subnormal temperature and the lowered blood-pressure 
of shock. 

C. Subtemporal decompression and drainage performed after the signs 
of meningitis had appeared. 

Case 84. — Acute severe brain injury with no signs of high intracranial 
pressure ; fracture of base of skull. Meningitis ; right subtemporal decom- 
pression and drainage. Death. Post-mortem examination. 

No. 032. — John. Twenty-four years. White. Single. Farmer. U. S. 
Admitted April 10, 1913 — 30 days after injury, Muhlenburg Hospital, 
Plainfield, N. J. Referred by Doctor Van Horn. 




Fig. 117. — Wide linear fracture extending into 
right middle fossa in a patient dying from a 
purulent meningitis, resulting from the intro- 
duction of bacteria at the time of the right 
subtemporal decompression — inexcusable and 
most careless. 



ACUTE BRAIN INJURIES 375 

Operation (June 8, 1913 — 58 days after admission and 88 days after 
injury). — Right subtemporal decompression and drainage. 

Died June 22, 1913 — 14 days after operation, 72 days after admission, 
and 102 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Thirty days before admission, patient was struck over 
the head by a large wooden beam ; immediate loss of consciousness ; treated 
at home with the expectant palliative method. His general condition im- 
proved, although the bloody discharge from the right ear continued for 
almost one week and then it became a thin watery purulent discharge ; 
on account of being ' ' feverish ' ' and complaining of dull headache, associated 
with dizziness, patient was brought to the hospital for treatment. 

Examination upon admission (30 days after injury) . — Temperature, 99° ; 
pulse, 72 ; respiration, 20 ; blood-pressure, 136. Rather drowsy but otherwise 
normal ; no external signs of scalp injury. Thin purulent discharge from 
right ear ; no mastoid ecchymosis or tenderness. Bacteriological report — nu- 
merous streptococci. Pupils equal and react normally. Reflexes — patellar ex- 
aggerated but equal ; no Babinski. Fundi negative. X-ray — negative report. 

Treatment. — Expectant pall iative. 

Examination (58 days after admission and 88 days after injury) . — (Upon 
a visit to the hospital to operate upon another patient, I was asked to examine 
this patient whose condition had not improved but had become worse several 
hours ago.) Temperature, 99.4°; pulse, 88; respiration, 26; blood-pres- 
sure, 134. Confused mentally and complains of severe frontal and occipital 
headaches, and "I feel chilly all over." Definite rigidity of neck with 
double positive Kernig reflex. Pupils equal and react normally. Reflexes — 
patellar very much exaggerated — left possibly greater than right ; exhaust- 
ible left ankle clonus and left Babinski; abdominal reflexes present and 
equal. Fundi — retinal veins dilated ; papilledema of both optic disks having 
a measurable swelling of 1 diopter. Lumbar puncture — slightly turbid cere- 
brospinal fluid under increased pressure (approximately 16 mm.) ; bac- 
teriological report — occasional streptococcus. 

Treatment. — In the belief that an early right subtemporal decompression, 
exploration and drainage might still be sufficient to obtain a recovery of life, 
and in the hope that the condition of mild meningitis might be due to a 
brain abscess of the right temporo-sphenoidal lobe, a right subtemporal de- 
compression was advised as the patient's only chance of recovery of life. 
(The presence of streptococci in the cerebrospinal fluid at lumbar puncture. 
we now know, made the prognosis practically hopeless as far as a recovery 
of life might be obtained by any operative means of drainage, etc. ; and even if 
a recovery of life could be obtained under these conditions, the ultimate 
result would not be a normal individual.) 

Operation (58 days after admission and 88 days after injury). — Right 
subtemporal decompression, exploration and drainage: usual vertical inci- 
sion, bone removed and no complications. Dura very tense and upon incising 
it, turbid cerebrospinal fluid escaped under high pressure (bacteriological 
report — numerous streptococci) ; upon enlarging dural opening, a congested 



376 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and slightly hazy cortex tended to protrude but did not rupture ; in the sulci 
about the vessels was a distinct whitish subarachnoid exudate. A ventricle 
puncture needle was used to locate, if possible, a brain abscess, but all attempts 
were unsuccessful. So much cerebrospinal fluid had escaped during the oper- 
ation that the cortex had become slightly relaxed, so that it pulsated. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 50 minutes. - 

Post -operative Notes. — Patient drained freely through the operative in- 
cision, became conscious after 24 hours and at the end of 56 hours the tem- 
poral margins of both optic disks were visible at an ophthalmoscopic exam- 
ination and the general condition of the patient so improved, during the 
following 6 days, that an ultimate recovery of life was even expected. On 
the eighth day post-operative, the temperature suddenly ascended to 106°, 
pulse to 138, and the respiration to 36 ; patient became comatose, and this 
condition steadily progressed until the patient died, 14 days after operation. 

Post-mortem Examination. — An examination through the operative in- 
cision revealed a diffuse meningitis with much free pus in the middle fossa. 
No brain abscess could be found. 

Remarks. — The condition of meningitis in the patient undoubtedly 
developed from the right middle ear infection — this complication occurring 
in a very small percentage of the cases, especially when the ear is irrigated, 
plugged or otherwise "meddled" with. The diagnosis of a possible brain 
abscess was due chiefly to the subacute character of the meningitis and also to 
the mild increased intracranial pressure to the extent of only a papilledema of 
one diopter of swelling ; it is rare for the condition of brain abscess by itself 
to produce the condition of high intracranial pressure, and especially that 
of ' ' choked disks ' ' of more than 2 diopters of swelling, because brain abscesses 
replace brain tissue by substitution and therefore they do not tend to 
increase the intracranial pressure as do brain tumors (the gliomatous tumors 
excepted, which also replace brain tissue) ; if the brain abscess should 
cause a meningeal irritation to the extent of even a meningitis by direct 
extension or rupture into the ventricles so that a diffuse meningitis occurs, 
then the intracranial pressure may be increased to an extreme degree by 
either a blockage of the ventricles and thus producing an internal hydro- 
cephalus, or by blocking the normal channels of excretion of the cerebrospinal 
fluid into the cortical veins, sinuses, etc., and thus in reality an external 
hydrocephalus results. As a point, therefore, in the differential diagnosis 
of brain abscess and brain tumor, the presence of ' ' choked disks " of 2 diop- 
ters and more always tends to indicate the condition of brain tumor 1 rather 
than brain abscess, even if the abscess is cerebellar and there are no marked 
signs of meningeal irritation — and especially in the absence of a meningitis. 

It is unfortunate that a complete autopsy of the head could not have 
been obtained in this patient ; these examinations through cranial operative 
incisions are most unsatisfactory and very little can be ascertained by means 
of them ; if permission is obtained before the operation (and it always should 
be in these patients), then it would always be possible to prevent the same 
operative mistakes from occurring and it would also afford an opportunity 
to ascertain the true intracranial condition for the benefit of the treatment 
of future patients. 



ACUTE BRAIN INJURIES 377 

Aright subtemporal decompression and exploration was performed upon 
this patient chiefly because the line of fracture extended through the right 
ear from which a purulent discharge had persisted for several weeks, and 
also to the increased reflexes of the left side of the body — particularly of a 
left Babinski. In the presence of a purulent meningitis, the site of the 
fracture of the skull is of real importance and is an aid to the localization 
of the intracranial lesion. 

It w r as a distinctly dangerous procedure, and even unsurgical, to have 
used a ventricle puncture needle in an effort to locate a subcortical cerebral 
abscess when it was necessary to pass this needle through the visible sub- 
arachnoid purulent exudate ; if the abscess was not found, then an abscess 
would almost certainly result from the exploratory puncture, and if an 
abscess was found then the ultimate outcome would be most doubtful on 
account of the presence of this supracortical purulent exudate. The fact 
also that the brain pulsated after the escape of a large quantity of cerebro- 
spinal fluid would have indicated that a subcortical abscess was not present, 
for the abscess usually causes a marked protrusion of the cortex and the 
so-called ' ' dry ' ' brain. 

Case 85. — Acute severe brain injury with mild signs of increased intra- 
cranial pressure; fracture of vault and base of skull. Meningitis. Right 
mastoiditis ; mastoidectomy. Brain abscess ; left subtemporal decompression 
and drainage. Death. Autopsy. 

No. 915. — Bella. Forty years. White. Married. School teacher. Ireland. 

Admitted November 6, 1917 (6 days after injury), Polyclinic Hospital. 

First Operation. — Right mastoidectomy — January 10, 1918 — 70 days 
after injury. 

Second Operation. — Left subtemporal decompression and drainage — 
March 18, 1918 — 138 days after injury and 68 days after first operation. 

Died May 8, 1918 — 188 days after injury and 50 days after 
second operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was knocked down 
by an automobile ; immediate loss of consciousness ; taken in the ambulance 
to Fordham Hospital, where she remained 6 days ; patient was in a condition 
of severe shock with multiple contusions over head and body and bleeding* 
from the right ear ; upon the disappearance of the signs of shock, her general 
condition improved, and patient was transferred to the Polyclinic Hospital. 

Examination upon admission (6 days after injury). — Temperature. 
101.6°; pulse, 84; respiration, 26; blood-pressure, 122. Fairly well devel- 
oped and nourished. Mildly irrational and very irritable. Ecchymosis of 
both orbits and both mastoid areas. Infected laceration of the scalp over right 
occipital area, Clotted blood in right external auditory canal ; otoscopic 
examination reveals a small laceration of lower posterior portion of right 
tympanic membrane. Pupils: slightly dilated but react to light normally: 
left possibly larger than right. Reflexes: patellar, exaggerated but equal: 
no ankle clonus nor Babinski ; abdominal reflexes absent. Fundi : retinal 
vessels enlarged; upper nasal quadrant of both optic disks blurred — right 






3/8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



more than, left. Lumbar puncture — bloody cerebrospinal fluid under high 
pressure (18 mm.). 

Treatment. — Expectant palliative. It was hoped that the patient would 
be able "to take care of" the increased intracranial pressure by the normal 
means of absorption and thus an operation be avoided. X-ray (Dr. G-. "W. 
Walton) — "linear fracture of right occipital bone into right mastoid " 
(Fig. 118). The condition of the patient, however, did not improve and 6 
days later, when the signs of increasing intracranial pressure became more 
and more marked as exhibited in both fundi by ophthalmoscopic examination, 
a subtemporal decompression was advised as the safer method of lessen- 
ing the intracranial pressure and to permit a greater ultimate as well 
as an earlier recovery: the operation, however, was refused at this time. 
Patient was, therefore, treated expectantly, but she never regained her nor- 
mal mental, emotional and physical condition so that she was obliged to re- 
main in the hospital in prac- 
tically this same condition of 
mental confusion, irritability 
and gradual physical weak- 
ness for a period of over 2 
months. On December 15, 
1917 (45 days after the in- 
jury), patient complained of 
stiffness of the neck and 
seemed more irrational than 
usual. Definite slight rigidity 
of the neck with a mild dou- 
ble Kernig sign ; lumbar 
puncture — turbid cerebro- 
spinal fluid under increased 
pressure (14 mm.) ; bacterio- 
logical report (Dr. Jeffries), 
' ' numerous streptococc i. ' ' 
Patient was naturally considered ;< hopeless" and this prognosis was given 
to the relatives. Fortunately, however, after 2 days, patient improved so 
much that she became rational again, the rigidity of the neck lessened and 
the double Kernig sign disappeared; 2 days later, a lumbar puncture 
revealed clear cerebrospinal fluid under an increased pressure of 12 mm., 
and the bacteriological report was negative except for an increased cell 
count of 11 per cubic mm. ; no bacteria found. Her condition continued 
in this slightly improved manner until January 9, 1918, when the patient 
developed distinct tenderness over the right mastoid area (into which the 
wide fracture from the occipital protuberance had extended). Doctor 
J. M. Smith, in consultation, advised a right mastoidectomy, which he 
performed on January 10. 1918 — 70 days after injury: much pus and 
necrosed bone cells removed and the patient made an excellent recovery 
from this operation so that, as her general condition now improved, she 
was able to leave the hospital on January 26, 1918 — 86 days after injury. 
On February 18, 1918 — 22 days after discharge — while patient was in the 




Fig. 118. — Huge linear fracture of right occipital bone extending 
into the right mastoid area in a patient developing later a puru- 
lent mastoiditis and requiring the operation of mastoidectomy. 



ACUTE BRAIN INJURIES 379 

out-patient department of the neuro-surgical clinic of the hospital, she sud- 
denly began to have convulsive twitches of the right side of the face, then the 
right arm, right leg and then a general convulsion occurred which lasted 
almost one minute ; patient was immediately admitted to the hospital, where 
the following examination was made : 

Examination (March 8, 1918 — 128 days after injury). — Temperature, 
99.4° ; pulse, 90 ; respiration, 26 ; blood-pressure, 128. Perfectly conscious, 
but in poor condition physically — very much emaciated. Definite weakness 
of right side of face (cortical type in that right forehead muscles were not 
involved). Distinct motor and sensory aphasia (patient and relatives all 
right-handed). Upon percussion, indefinite area of tenderness over the left 
temporal region. Pupils — left larger than right and reacts sluggishly to light. 
Reflexes : patellar, very active, right greater than left ; right ankle clonus and 
right Babinski ; abdominal reflexes — right absent, left depressed. Fundi : 
retinal veins enlarged ; nasal halves of both optic disks blurred — left possibly 
more than right. Lumbar puncture: clear cerebrospinal fluid under in- 
creased pressure (14 mm.) ; cell count, 16 cells per c.mm. ; no bacteria found. 

Treatment. — For fear a localized meningitis was occurring or that a 
brain abscess was in process of being formed, a left subtemporal exploration 
and drainage was advised; permission for the operation was not obtained 
until 10 days later — the patient's condition remaining practically the same. 

Second Operation (March 18, 1918 — 138 days after injury). — Left sub- 
temporal decompression, exploration and drainage : usual vertical incision, 
bone removed and no complications. Dura thickened, opaque and under 
moderate tension; upon incising it, a small amount of cerebrospinal fluid 
escaped, and upon enlarging dural opening, the underlying cortex tended to 
protrude but did not rupture ; upon the cortex, especially in the sulci about 
the vessels, was a greyish subarachnoid exudate (the result of the former 
meningitis). The cortex itself did not pulsate; upon exploring the lower 
fronto-parietal area with a ventricle puncture needle, thick creamy pus 
welled up through the needle from an abscess cavity situated 4 cm. beneath 
the cortex in the posterior portion of the left frontal lobe ; the double glass 
tubes for drainage were now inserted, allowing almost 3 ounces of rather 
thick pus to escape. Bacteriological report (Dr. Jeffries) — "staphylococci. " 
Usual closure with 2 drains of rubber tissue inserted. Duration, 55 minutes. 
Post-operative notes : Patient made a marked improvement within 10 days 
after operation ; the right facial weakness disappeared, the motor and sen- 
sory aphasia improved while the signs of intracranial pressure became less 
marked; the temperature did not rise above 101°, and there were at no time 
any signs of meningeal irritation — such as rigidity of the neck, convulsions 
or a Kernig sign. Patient continued to improve until April 10, 191S (22 
days after the drainage operation), when she gradually became stuporous. 
paralysis of the right side of the face again appeared and of the cortical 
type, the left decompression area bulged and the reflexes of the right side 
of the body again became very active, including a right ankle clonus and a 
right Babinski ; the patient was taken to the operating room, the upper por- 
tion of the decompression incision reopened and double glass drainage tubes 
again inserted into the abscess cavity which was becoming enlarged again by 



380 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



LINE OF 
FRACTURE. 



its blockage ; the usual post-operative treatment was given, but the patient 
had become so weakened and emaciated by the long illness that her condi- 
tion gradually became worse — having no longer any resistance left, and,, 
although no signs of an acute condition occurred, such as meningitis, etc., 
the patient finally died on May 8, 1918 — 188 days after injury — a death 
typical of infection and exhaustion. 

Autopsy. — A fracture, of one-quarter inch in width, extended from the 
posterior occipital protuberance forward into the right mastoid and then 
along the right petrous bone to within one-half inch of the sella turcica ; orbi- 
tal plate of left frontal bone contained a small linear fracture 5 cm. in length 
(Fig. 119). Anterior surface of left frontal lobe lacerated; no extradural 

nor subdural hemor- 
rhage present. Over en- 
tire right cerebral cortex 
was a thin subarachnoid 
hazy exudate, particu- 
larly in the sulci about 
the vessels and less so 
over the left cerebral 
cortex (the results of the 
former meningitis) . 
Situated in the posterior 
portion of the left 
frontal lobe and extend- 
ing backward into the 
left parietal and left 
temporal lobes was a 
subcortical abscess, the 
size of an orange, which 
had been incompletely 
drained and was par- 
tially filled with a thick 
grumous mucoid mate- 
rial — the debris of former brain tissue ; its depth from the cortex was 3 cm. 
It had not ruptured into the left ventricle, but was only 1 cm. from it. No 
other abscesses found. Ventricles negative. No signs of an acute meningitis 
present as the cerebrospinal fluid in the posterior fossa was clear, but there 
was over the cortex of the cerebellum the thin subarachnoid exudate of the 
former meningitis. Bacteriological report ( Doctor Jeffries ) , ' ' staphylococci. ' ' 
Remarks. — In many respects, this case is almost unique; it is possible 
that all of these various complications could have been avoided and the 
patient have made an uneventful recovery if a simple right subtemporal 
decompression could have been performed early — within the first week after 
her admission to the Polyclinic Hospital when the signs of an increased 
intracranial pressure were at their height and the patient was in a good 
general physical condition. After the patient had remained for a period 
of a week in a stuporous condition and the body resistance had been greatly 
lessened, it was then very easy for an infection to occur and thus apparently 




Fig. 119. — Extensive wide fracture of right occipital bone ex- 
tending forward to right mastoid area and along the crest of right 
petrous bone; a linear fracture of the left anterior fossa. This patient 
developed a purulent meningitis with apparent recovery; then a right 
mastoiditis and the subsequent formation of a brain abscess and the 
patient's death. 



ACUTE BRAIN INJURIES 381 

a low-grade meningitis did result clinically, although the bacteriological re- 
port was "numerous streptococci" — and naturally the prognosis was bad. 
It was most surprising, therefore, to have the patient recover from this 
diffuse meningitis — only to develop a right mastoiditis and apparently to 
obtain an excellent recovery, so that the patient was able to leave the hos- 
pital as ' ' cured. " As a sequela of the former meningitis, Jacksonian con- 
vulsions began 128 days after the injury and 83 days after the onset of the 
meningitis, and it was the left cerebral hemisphere and not the right one con- 
tiguous to the line of fracture and the mastoid, which was the site of the 
abscess with irritation of the overlying cerebral cortex. To have been able 
to locate and to drain the abscess successfully was most gratifying, and again 
to have the patient return home as ' ' cured ' ' — the relatives having now been 
told twice that the patient's condition was practically a hopeless one and 
each time the patient recovered. However, the abscess had not been success- 
fully drained so that the patient could recover and the general condition 
becoming weaker and, weaker, she died apparently from exhaustion — there 
being no signs at autopsy of an acute meningitis which was to be expected. 
From an operative standpoint, the absence of meningitis as the immediate 
cause of death was gratifying in that this complication is the most common 
one to be associated with and following the condition of brain abscess. 

The autopsy findings revealing multiple lacerations of the anterior sur- 
face of the left frontal lobe and directly opposite to the site of the cranial 
injury and area of contact in the right occipital region, is clearly one of cere- 
bral trauma au contre-coup. Even the smaller linear fracture of the orbital 
plate of the left frontal bone may also be considered as a resulting fracture 
au contre-coup. 

Acute Brain Injuries, with and without a Fracture of the Skull, and 
Their Other Most Frequent Complications. 

Brain injuries of any severity occurring in patients over 50 years of 
age or in patients having a chronic cardio-renal and cardio-vascular condi- 
tion, and, in fact, any chronic condition which tends to lessen the general 
resistance of the patient — these injuries must be considered as serious ones, 
even though the original intracranial damage is little if any at all. If the 
intracranial lesion is not a serious one in itself, yet the associated stupor 
and even unconsciousness necessitating a convalescence of days and even 
several weeks in bed, predispose these patients to many complications other 
than those directly connected with the cranial injury, such as shock, infec- 
tion, etc. The most common serious complications of these patients are 
pneumonia in the elderly ; delirium tremens in the alcoholic : mental derange- 
ment in the unstable psychically; exacerbations of any chronic organic con- 
dition, such as arteriosclerosis, nephritis and diabetes, and thus increasing 
the danger of an acute cerebral edema; and then, and of greater frequency 
than is usually supposed, the precipitation of the symptoms and signs of 
latent lues in its various manifestations, and especially those of cerebrospinal 
lues and paresis, and it would seem in these latter patients that an active 
meningeal process was "lighted," so that the former latent condition now 
appears clinically for the first time; the value of routine physical and 



3 82 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



neurological examinations with careful laboratory tests of the blood, cerebro- 
spinal fluid and of the urine cannot be overestimated. 

Beside these more common complications occurring in brain injuries, 
there are those patients in whom the condition of brain tumor has been 
present in a latent condition clinically, and its symptoms and signs suddenly 
appear following a cranial injury ; these cases are most confusing at the time 
and the lesion of tumor formation is frequently "stumbled upon" at the 
operation. Cranial injuries of months' or of years' duration may precede 
and even be in some patients an etiological factor of tumor formation either 
of the skull, meninges or of the brain itself; this statement, however, cannot 
be made with certainty. 

Acute severe brain injuries complicated by other conditions. 

A. Delirium tremens. 

Case 86. — Acute severe brain injury associated with mild signs of 
intracranial pressure and a fracture of the base of the skuli. No operation. 
Delirium tremens. Death. Autopsy. 

No. 697. — James. Forty years. White. Married. Laborer. U. S. 

Admitted October 7, 1916 — 2 hours after injury — Polyclinic Hospital. 

Died October 13, 1916 — 6 days after injury. 

Family history negative. 

Personal history negative, except for chronic alcoholism. 

Present Illness. — Patient was found lying at the bottom of a stairway; 
unconscious; brought to the hospital in the ambulance. 

Examination upon admission (at least 2 hours after injury). — Tem- 
perature, 101.8°; pulse, 118; respiration, 26; blood-pressure, 122. Uncon- 
scious ; stertorous respiration and signs of an early pulmonary edema — moist 
rales throughout chest. Marked odor of alcohol on breath. Small contusion 
and hematoma over right temporal area. Slight bloody discharge from right 
ear : distinct right mastoid ecchymosis. Pupils slightly enlarged and react 
sluggishly to light. Reflexes — patellar exaggerated but equal; double ex- 
haustible ankle clonus and double Babinski, Oppenheim and Gordon reflexes ; 
abdominal reflexes absent. Fundi — retinal veins dilated; both retinae suf- 
fused and congested with edematous blurring about the margins of the optic 
disks. Lumbar puncture — bloody cerebrospinal fluid under increased pres- 
sure (approximately 15 mm.). 

Treatment. — Expectant palliative; repeated doses of atropine (grains 
1 / 60 hypodermically) every 3 hours to control the pulmonary edema; on 
account of the poor general condition of the patient — the pulse-rate being 
118 while the blood-pressure w T as only 122, it was decided to "watch" the 
patient carefully in the hope that the condition would improve. Within 
24 hours, the temperature had descended to 100°, the pulse to 104 and the 
respiration to 24, while the blood-pressure had risen to 136 and patient had 
become semiconscious ; the pulmonary rales had almost disappeared and as 
the signs of the increased intracranial pressure had not become more marked, 
it was believed that the patient would recover without an operation being 
necessary — that is, the intracranial hemorrhage and the cerebral edema 
would be absorbed by the natural means of excretion from the cerebrospinal 
canal. On the second day after admission, however, the patient suddenly 






ACUTE BRAIN INJURIES 



383 



developed a fine and then a coarse tremor of both hands, became mentally 
confused and irrational, had definite hallucinations of sight — the typical 
signs of beginning delirium tremens. In spite of active treatment for this 
condition (repeated lumbar punctures, the administration of alcohol, mor- 
phia, hot packs, etc.), the patient steadily became worse and finally died 
from the typical condition of "wet" brain, resulting from the so-called 
delirium tremens — 6 days after injury. 

Autopsy. — Linear fracture extended from right parietal crest vertically 
downward through the squamous portion of the right temporal bone, through 
the posterior portion of left tympanic membrane along the petrous bone to 
within one inch of its apex ; no other fracture found (Fig. 120) . Much blood 
and cerebrospinal fluid, particularly in the middle and posterior fossae. Brain 
itself very * ' wet ' ' and edematous, but 
no cortical hemorrhage or laceration. 
Ventricles negative. 

Remarks,. — If this complication of 
delirium tremens had not occurred, it 
seems that this patient would have 
recovered. It was a mistake not to 
have administered alcohol to this 
patient, either by mouth or by rectum, 
so that the onset of acute alcoholism 
could have been avoided if possible ; all 
patients accustomed to the daily use 
of alcohol, and particularly having a 
cranial injury of any severity, should 
be given daily at least one-half their 
usual allowance of alcohol and thus 
the danger of delirium tremens be 
lessened. It is a well-known observa- 
tion, however, that patients who are at all alcoholic withstand very poorly 
the effect of head injuries owing to- the fact that a cerebral edema occurs 
much more easily in these patients, so that, even if alcohol were given after 
their admission to the hospital, the cerebral edema precipitating delirium 
tremens would frequently occur in spite of this precaution. Chronic 
alcoholics are very poor risks, whether an operation is performed or not, 
and there is no one factor which increases the mortality of brain injuries 
more than that of chronic alcoholism. 

The clinical picture of this patient upon admission having a temperature 
of 101.8°, pulse 118, respiration 28, blood-pressure 122, would indicate that 
the patient was in the condition of mild shock with the lowered blood-pressure 
and the increased pulse-rate, while the mild temperature was due to the 
early signs of pulmonary edema associated with chronic alcoholism: this 
opinion would tend to be substantiated by the observation that 24 hours 
later the temperature descended to 100° and not to subnormal and the pulse 
to 104, while the blood-pressure increased to 136, synchronous with the 
lessening of the pulmonary edema. 

Case 87. — Acute severe brain injury associated with mild sians of high 




Fig. 120. — Wide linear fracture extending 
through the right petrous bone in a patient who 
would probably have recovered if the complica- 
tion of delirium tremens had not occurred. 



384 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

intracranial pressure and a fracture of the base of the skull. No operation, 
on December 2, 1914 — 29 days after injury. 

No. 169. — John. Thirty-two years. White. Single. Storekeeper. Greece. 

Admitted November 3, 1914 — 1% hours after injury, Polyclinic Hospital. 

Transferred to Bellevue Hospital November 6, 1914; discharged "well," 
on December 2, 1914 — 29 days after injury. 

Family history negative. 

Personal History.— As the result of a profitable sale of his store, patient 
has been drinking heavily during the past 6 weeks and his friends say "his 
only hope is in his losing his money." 

Present Illness. — While Intoxicated, patient was "black-jacked" by 
thugs who obtained the balance of patient's money; unconscious; brought 
to the hospital in the ambulance. 

Examination upon admission (90 minutes after injury). — Tempera- 
ture, 99° ; pulse, 88 ; respiration, 24 ; blood-pressure, 130. Semiconscious but 
can be easily aroused ; mildly delirious and behaves foolishly. Marked tremor 
of both hands. Contusion and ecchymosis over left eye and left lower 
jaw. Slight bleeding and discharge of bloody cerebrospinal fluid from left- 
ear; distinct left mastoid ecchymosis. Pupils equal and react normally. 
Reflexes negative. Fundi negative. Lumbar puncture — blood-tinged cere- 
brospinal fluid under moderate pressure (approximately 13 mm.). 

Treatment. — Expectant palliative ; small amounts of alcohol given to the 
patient and the routine prophylactic treatment for chronic alcoholism. In 
spite of this treatment, however, patient progressively became worse in that 
the hallucinations became more realistic to him, associated with an acute 
delirium, requiring restraint, so that 3 days after admission, it was considered 
advisable that the patient be transferred to the alcoholic ward of Bellevue 
Hospital, where he could be treated more competently for this complication. 
His record at Bellevue was that of a typical case of delirium tremens; the 
recovery was uneventful and the patient was discharged as "cured" — 29 
days after injury. 

Last Examination (May 20, 1917 — 31 months after injury). — Patient no 
longer drinks and has no complaints ; he has acquired a small grocery store 
from his savings during the past 2 years. Hearing — no impairment of either 
ear can be elicited ; otoscopic examination of left ear negative ; air conduc- 
tion greater than bone conduction. Reflexes negative. Fundi negative. 

Remarks. — This patient, being a youthful adult, had a greater chance of 
recovery both from the cranial injury and from the attack of acute alcoholism 
than if he had been 15 years older and more addicted to the chronic use 
of alcohol — then, the prognosis as to life would have been much more doubt- 
ful. The fracture of the skull through the ear and thereby allowing the 
intracranial hemorrhage to escape was most fortunate for him in that the 
increased intracranial pressure was undoubtedly lessened and thus enabled 
him, not only to recover much more easily, but much more rapidly and with- 
out a cranial operation. 

The absence of permanent impairment of hearing in many of these 
patients having fractures of the skull which have extended through either 
ear is very interesting ; it occurs in possibly 20 per cent, of these patients. 



ACUTE BRAIN INJURIES 385 

It would seem that patients of middle age and older who are addicted 
to the daily use of alcohol for over a period of years and if only in moderation, 
that there is an increased amount of cerebrospinal fluid normal to these 
patients — that is, a mild degree of the so-called "wet" brain. Any severe 
illness, and particularly a cranial injury, which upsets their body metabolism 
and in any way diminishes their daily supply of alcohol, then these patients 
are very liable to develop an acute condition of cerebral edema and thus 
the typical onset of delirium tremens occurs. The mild toxic condition 
resulting from this daily continued use of alcohol lessens the power of 
resistance of these patients and they are much more liable to succumb 
to any severe mental and physical strain. They are always "bad" operative 
risks, including the greater danger of anesthetic complications, and the prog- 
nosis must be very guarded, especially following cranial injuries. 

B. Brain tumor. 

Case 88. — Acute severe brain injury associated with definite signs of 
an increased intracranial pressure and with an operative fracture of base of 
skull. Bilateral decompression and drainage. Death. Autopsy; mid- 
brain sarcoma. 

No. 794. — James. Forty years, White. Married. Laborer. U. S. 

Admitted February 29, 1917 — 10 days after operative injury. Poly- 
clinic Hospital. 

First Operation (March 2, 1917 — 2 days after admission and 12 days 
after operative injury). — Left subtemporal decompression and drainage. 

Second Operation (March 4, 1917 — 2 days after first operation and 14 
days after injury). — Right subtemporal decompression and drainage. 

Died March 8, 1917 — 4 days after second operation and 18 days 
after injury. 

Family history negative. 

Personal History. — During the past 6 months, patient has been treated at 
an Eye and Ear Hospital for chronic inflammation of the ethmoid and 
sphenoid sinuses and also for a chronic right otitis media ; several operations 
had been performed upon both the ethmoid and sphenoid sinuses and the 
right middle ear ' ' cleaned out. ' ' Patient was improved for several weeks and 
then his symptoms and signs returned — particularly the frontal headache, 
the purulent discharge from the nose and the spells of dizziness. 

Present Illness. — On February 19, 1917 (10 days before admission V 
patient was operated upon and the sphenoidal cells opened and evacuated : 
immediately after this operation, patient became stuporous, complained of 
severe bifrontal headache and was mildly irrational ; 3 days before admis- 
sion, patient suddenly became blind in both eyes, stupor increased and the 
patient complained of an increasing deafness in both ears. Transferred to 
the hospital in the ambulance. 

Examination upon admission (10 days after the sphenoidal sinus opera- 
tion). — Temperature, 99.8° ; pulse, 72; respiration, 20; blood-pressure, 142. 
Semiconscious but can be easily aroused. Slight purulent discharge from 
the right ear. Thin bloody discharge from both nostrils. Totally blind in 
both eyes — not even light perceived; external ocular muscles all paralyzed 
(ophthalmoplegia externa) so that both eyeballs cannot be moved. Hearing 
25 



386 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

of both ears apparently impaired. Slight right facial weakness of the cortical 
type. Pupils moderately dilated and do not react to light. Reflexes — patel- 
lar can be elicited with difficulty and are apparently equal ; no ankle clonus 
nor Babinski ; abdominal reflexes absent. Fundi — retinal veins dilated ; both 
nasal and temporal margins blurred and indistinct but no papilledema 
or measurable swelling of either optic disk. Lumbar puncture — clear cerebro- 
spinal fluid under high pressure (18 mm.) ; cell count — 6 cells per c.mm. and 
no bacteria present. No weakness of extremities and no sensory impairment 
could be elicited. X-ray "negative" (Doctor W. H. Stewart). 

Treatment. — On account of the increased intracranial pressure and the 
appearance of a right facial palsy of the cortical type, a left subtemporal 
decompression and exploration was advised ; consent for the operation could 
not be obtained until 40 hours later, and as the condition of the patient 
was practically the same as at the preceding examination, the operation 
was now performed. 

First Operation (2 days after admission and 12 days after operative 
injury). — Left subtemporal decompression and exploration: usual vertical 
incision, bone removed and no complications. Dura very tense and slightly 
bluish ; upon incising it, blooody cerebrospinal fluid spurted to a height of 
5 inches; upon enlarging dural opening, the underlying cerebral cortex 
tended to protrude under high tension ; it did not rupture, however, but 
only slight pulsation could be observed. Cortex contained several small 
punctate hemorrhages and much subarachnoid blood and cerebrospinal fluid 
escaped. An attempt to tap the left lateral ventricle not successful and 
careful probing of the left frontal lobe, left parietal lobe and left temporo- 
sphenoidal lobe for brain tumor was negative. Usual closure with 2 drains 
of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — The stupor of patient improved for 24 hours and 
then he gradually became semiconscious again, the decompression area bulged 
and the signs of an increasing intracranial pressure reappeared; a right 
subtemporal decompression was now considered advisable both to lessen 
the intracranial pressure and in the hope that a tumor or abscess could be 
located in the right hemisphere, or if it was merely a cerebral edema, then its 
resulting increased pressure could be successfully lessened. (The sudden 
impairment of vision could not be explained as well as the ophthalmoplegia 
externa, unless the condition was a mid-brain tumor which by a sudden en- 
largement had directly compressed both optic nerves and the ocular nerves.) 

Second Operation (2 days after first operation and 14 days after injury). 
— Right subtemporal decompression and exploration : usual vertical incision, 
bone removed and no complications. Dura very tense and upon incising it, 
slightly blood-tinged cerebrospinal fluid welled through dural opening under 
high pressure — revealing a very "wet," edematous cortex which tended to 
protrude but did not rupture, owing to the escape of a large amount of 
cerebrospinal fluid, so that the cortex pulsated normally at the end of 
the operation. Right lateral ventricle punctured, allowing clear cerebro- 
spinal fluid to escape under moderate pressure. Careful exploratory punc- 
tures of the right frontal, right parietal and right temporo-sphenoidal lobes 



ACUTE BRAIN INJURIES 



387 



were all negative. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 50 minutes. 

Post-operative Notes. — Patient made a marked improvement during the 
first few days after operation in that he became conscious, was able to talk 
rationally and he no longer complained of headache ; the vision, however, did 
not improve, and on the third day post-operative, the temperature quickly 
ascended to 105°, pulse to 138 and respirations to 36; both decompression 
areas bulged tensely, while the patient became more and more stuporous. 
Lumbar puncture revealed clear cerebrospinal fluid under moderate increase 
of intracranial pressure (13 mm.) ; cell count was 10 cells per c.mm. ; the 
condition of patient rapidly became worse, pulmonary edema occurred, and 
in spite of vigorous stimulative measures and the use of atropine, the patient 
became weaker and weaker and 
finally died — 4 days after second 
operation and 18 days after injury. 

Autopsy. — Upper portion of 
sphenoidal plate had been fractured 
just in front of the anterior clinoid 
processes and in close proximity to 
both optic nerves (Fig. 121). Much 
free subdural blood in both the 
anterior and middle fossae, while an 
extensive blood-clot lay upon the 
inferior surface of both frontal 
lobes. In the mid-brain superimpos- 
ing the sella turcica and both optic 
nerves, which were being directly 
compressed from above downward, 
was a hard fibrous tumor — the size 
of an orange. (Pathological report 
(Doctor Jeffries) — "spindle-cell sarcoma") ; this tumor mass lay beneath 
and slightly anterior to the third ventricle and thus the lateral ventricles 
had not been blocked ; this was very fortunate for the patient in that an in- 
ternal hydrocephalus did not develop. Posterior fossa negative. Ven- 
tricles negative. 

Remarks. — This is another case — and they are very common — of a mid- 
brain tumor simulating sphenoidal sinus disease ; the right chronic otitis 
media and the chronic sinusitis both tended to obscure the diagnosis, and it 
was not until a sudden complete loss of vision occurred associated with the 
ophthalmoplegia that a mid-brain lesion was suspected. In attempting 
to perform the sphenoidal sinus operation, the upper and posterior bony wall 
had been accidentally fractured with a resulting subdural hemorrhage 
from the adjoining venous sinus which fortunately became thrombosed early 
and did not extend to the other side. It was then, and apparently for the 
first time, that the signs of an increased intracranial pressure occurred 
necessitating the decompression operations. 

The tumor Avas of such a large size and so situated in the mid-brain that 
an operative removal of it could not have been attempted successfully; if it 




Fig. 121. — Operative fractures and perforation of 
median portion of sphenoidal bone in a pa ient dying 
from a large sarcoma of the mid-brain and superimposed 
upon the sella turcia — the cause for his symptoms and 
signs. 



388 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

had been smaller, it possibly could have been removed by the lateral approach 
— either by retracting the temporo-sphenoidal lobe upward, or, if necessary, 
the removal of the right temporo-sphenoidal lobe which permits an excellent 
exposure of mid-brain tumors and facilitates their successful enucleation, 
especially if a bilateral decompression has been performed so that the brain 
can be ; ' dislocated, ' ' and thus a better surgical exposure be obtained. 

The immediate cause of death in this patient was evidently an acute 
medullary edema precipitated by the general lowered resistance of the 
patient and the intracranial lesions. How this patient escaped a purulent 
meningitis through infection of the operative fracture of the base of the 
anterior fossa is difficult to explain in the presence of a purulent sphenoidal 
sinusitis. The sudden onset of blindness was probably due to an acute edema 
of the tumor itself or to small hemorrhages into the tumor itself (as dis- 
closed upon sectioning the tumor), and thus both optic nerves at the 
chiasm were markedly compressed; naturally, if this compression could 
not have been relieved and if the patient had lived for a period of weeks, 
the ophthalmoscope would have revealed definite signs of a primary optic 
atrophy. If this compression of both optic nerves had not been so great, 
then a lateral or horizontal hemianopsia would have occurred and this obser- 
vation would have facilitated the diagnosis very much indeed; the total 
ophthalmoplegia, should have emphasized the localization of the lesion more 
than it did, but at the time it was considered more of a retro-orbital or 
posterior orbital condition due to the inflammatory lesion of the sinuses. 
The value of post-mortem examinations not only to the medical attendant 
but to future patients, could not be more highly emphasized and appraised 
than in the case of this patient ; more is frequently learned from mistakes 
than from successes. 

The differential diagnosis before operation upon this patient was most 
perplexing : the history tended to indicate a brain abscess and meningitis, 
particularly associated with the sphenoidal sinusitis and the purulent otitis 
media ; the increased intracranial pressure, however, of a height of 18 mm. 
and yet the cerebrospinal fluid clear and with a cell count of only 6 cells per 
c.mm. and no bacteria present, tended to the diagnosis of brain tumor. It was 
most surprising, therefore, to find a subdural hemorrhage at operation, 
and it was then that the sphenoidal sinus operation was considered as the 
probable cause of the intracranial condition — being similar to a brain injury 
following a fracture of the skull, while the impairment of vision and 
ophthalmoplegia were due to a local injury at the time of the operation itself. 
The autopsy findings were indeed most instructive. 

Case 89. — Acute severe brain injury associated with definite signs of an 
increased intracranial pressure and with a fracture of the base of the skull. 
Left subtemporal decompression and drainage. Death. Autopsy; glioma 
of left temporo-sphenoidal lobe. 

No. 977. — Clara. Fifty years. White. Married. Housework. U. S. 

Admitted May 6, 1918 — 21 days after injury — Polyclinic Hospital. 
Referred by Doctor Adolph Reich. 

Operation (May 9, 1918 — 3 days after admission and 21 days after in- 
jury). Left subtemporal decompression and drainage. 



ACUTE BRAIN INJURIES 389 

Died May 10, 1918 — 26 hours after operation and 25 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — Twenty-one days before admission, patient was knocked 
down by a street car; immediate loss of consciousness and multiple con- 
tusions of both arms and legs ; slight bleeding from left ear ; patient was 
taken to her home in a taxicab, but she had so recovered on the way home 
that she walked into her house and did not go to bed. Definite impairment 
of speech, however, immediately appeared — unable to say words that she 
wished to; complained of headache but otherwise "fairly well." Seven 
days after injury, patient was obliged to be restrained in bed on account of 
her becoming irrational, staggered as though drunk and could not talk coher- 
ently ; complained of ' ' bad odors, ' ' and she could not be convinced that they 
were not present. On account of the increasing headache, the patient was 
brought to the hospital. 

Examination upon admission (21 days after injury). — Temperature, 
100°'; pulse, 84; respiration, 24; blood-pressure, 136. Mildly irrational. 
Definite weakness of entire right side of body ; also, a distinct impairment 
of sensation both to light-touch and to pain over the entire right side of the 
body. (This last observation could not be confirmed owing to the mental 
condition of the patient.) Otoscopic examination — laceration of lower pos- 
terior quadrant of left tympanic membrane. Pupils — left larger than right 
and reacts sluggishly to light. Reflexes — patellar not increased though right 
greater than left ; no ankle clonus but double Babinski, Oppenheim and Gor- 
don reflexes ; abdominal reflexes — right absent, left depressed. Fundi — ret- 
inal veins enlarged; nasal halves of both optic disks blurred — left more 
definitely than right, but no measurable swelling of the disks. Lumbar punc- 
ture — straw-colored cerebrospinal fluid under high pressure (20 mm.) ; 
pathological report (Doctor Jeffries) — "numerous broken-down red cor- 
puscles." Urine examination — slight trace of albumen; occasional hya- 
line cast. 

Treatment. — Expectant palliative. The condition of the patient, how- 
ever, became worse daily in that the signs of pressure became more marked 
in the fundi, and the weakness of the right arm and right leg progressed to the 
extent of almost a complete paralysis of them • the increasing stupor of the 
patient with a gradual lowering of the pulse-rate made a subtemporal 
decompression imperative, if the patient was to be given a chance to recover ; 
the pulse did not descend below 70, however, while the temperature ascended 
to 102.6°. 

Operation (24 days after injury). — Left subtemporal decompression (no 
anesthesia being necessary) : usual vertical incision, bone removed and no 
complications. Dura very tense and upon incising it, very little cerebro- 
spinal fluid escaped but the underlying cortex protruded through the small 
dural opening under high pressure, ruptured and brain tissue oozed out; 
an attempt was made to puncture the left lateral ventricle but unsuccessfully. 
Upon enlarging dural opening therefore owing to the high cerebral ten- 
sion, the entire underlying cortex ruptured, permitting gelatinous grumous 
degenerated nerve tissue and debris to extrude ami revealing a cavity in 



3QO DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






the left temporo-splienoidal lobe — the size of an orange. The condition of 
the patient becoming rapidly worse, a hurried closure was made with 2 drains 
of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes.— The condition rapidly became worse ; patient did 
not regain consciousness and within 8 hours the temperature had ascended 
to 106°, pulse to 140 and respiration to 42, while the blood-pressure had 
descended to 88. Patient died 26 hours after operation — from a condition 
typical of an acute medullary edema. 

Autopsy. — Small fracture of left petrous bone extending through left 
middle ear (Fig. 122). Small amount of straw-colored cerebrospinal fluid 
in both anterior and middle fossae. Anterior surface of right frontal lobe 
contused and lacerated ; also the tip of the right sphenoidal lobe. Occupying 
the entire left temporo-sphenoidal lobe w T as a cavity, the size of an orange, 
filled with degenerated brain tissue. (Pathological report (Doctor Jeffries) — 

' ' degenerated gliomatous tissue. ' ' ) 
Left ventricle had been collapsed and 
forced toward the median line. Pos- 
terior fossa negative. 

Remarks. — The clinical syndrome 
of this patient is very instructive; 
although this gliomatous tumor must 
have existed for a period of at least 
several months before the injury, yet 
there was no history of any com- 
plaints at all — the patient being con- 
sidered in the best of health. It is 
conceivable that the cranial injury, 
besides causing a contusion and 
laceration of the right frontal and 
right sphenoidal lobe by contre-coup, 
had also at the same time caused a 
hemorrhage into the tumor mass it- 
self in the left temporo-sphenoidal lobe or had at least precipitated the 
degeneration of the tumor mass itself by causing an acute cerebral edema, 
and thus introducing and then accentuating the symptoms and signs of 
a lesion of the left temporo-sphenoidal lobe (the patient being right- 
handed and all of his blood relatives being right-handed) : the disagreeable 
odors and the state of unreality — the relatives stated that before com- 
ing to the hospital, the patient complained of dreaming, and yet while 
she lay dreaming she knew that the dreams were not true and that 
these dreamy states of unreality persisted until she become irrational; no 
impairment of taste had been elicited nor any impairment of the hear- 
ing, however; the neighborhood signs of motor aphasia and both a motor 
and sensory involvement of the right side of the body were also to be 
observed. It is possible if the cranial injury had not occurred that this 
patient could have lived a number of months and even a period of one 
year or more before the symptoms and signs of the tumor mass would have 
been observed. If it had not been for this complication of tumor, the 




Fig. 122. — Linear fracture of left petrous bone, 
following a "bump" upon the head of a patient 
having a large gliomatous tumor of the left 
temporo-sphenoidal lobe. 



ACUTE BRAIN INJURIES 391 

operative recovery of the patient from the brain injury would have been 
very possible. Unfortunately, this patient had been allowed to progress to 
such a condition of general physical exhaustion, that a medullary edema 
occurred chiefly on account of the lessened resistance of the patient having 
an intracranial lesion of this character. 

It was a very confusing coincidence that the fracture of the skull in 
this patient passed through the left middle ear rupturing the left tympanic 
membrane, to be followed by definite symptoms and signs of a left temporo- 
sphenoidal lesion ; the unusually high intracranial pressure of 20 mm. at a 
period 3 weeks after the cranial injury is most unusual, and an intracranial 
tumor might have been suspected at this time as being the underlying cause 
of the patient's condition ; at the time, a possible large left extradural hemor- 
rhage was considered as being the cause of the condition. 

The inability to puncture the left lateral ventricle before the dura was 
widely opened and thus prevent an operative damage to the underlying 
cerebral cortex owing to the very high intradural pressure, is explained 
by the autopsy findings in which the left lateral ventricle was found to be 
forced downward and toward the median line and also collapsed by the 
pressure of the tumor mass in the left hemisphere ; a lumbar puncture might 
have been attempted at this time and by this means the intradural pressure 
lessened so that no operative damage to the underlying cerebral cortex 
would have occurred. 

C. Mental derangements. 

Case 90. — Acute severe brain injury associated with high intracranial 
pressure and with a fracture of the base of the skull. Left subtemporal 
decompression and drainage. Mental and emotional impairment. Recovery. 

No. 145. — Edwin. Fifty-eight years. White. Married. Broker. U. S. 

Admitted December 16, 1914 — 70 minutes after injury — Flower Hospital. 
Referred by Doctor G. R. Satterlee. 

Operation (December 19, 1914 — 3 days after injury). — Left subtem- 
poral decompression and drainage. 

Discharged January 29, 1915 — 40 days after injury. 

Family history negative. 

Personal History. — During the past 6 years, patient has had 2 very severe 
attacks of acute nephritis requiring a hospital residence of over 4 months 
each time ; marked arteriosclerosis. Patient has been considered eccentric 
and emotionally unstable for years. 

Present Illness. — While descending the subway stairs, patient fell head- 
long to the bottom ; immediate loss of consciousness ; taken to the Flower 
Hospital in ambulance ; patient remained unconscious and in severe shock ; 
profuse bleeding from the left ear. 

Examination (66 hours after admission. Consultation with Doctor 
Satterlee). — Temperature, 100°; pulse, 68; respiration, 20: blood-pressure, 
156. Semiconscious and exceedingly restless. Marked arteriosclerosis — 
radial arteries hard and tortuous and temporal arteries similarly affected. 
Small lacerations of the scalp posterior to the external angular process of left 
orbit. Clotted blood in left auditory canal; otoscopic examination reveals a 
large laceration of posterior half of left tympanic membrane ; extensive left 



3Q2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



mastoid ecchymosis. Pupils equally contracted and do not react to light. 
Reflexes — patellar exaggerated, right more than left; exhaustible ankle 
clonus and right Babinski ; abdominal reflexes present and equal. Fundi — 
retinal veins dilated; nasal margins of both optic disks and nasal half of 
left optic disk blurred by edema. Lumbar puncture — bloody cerebrospinal 
fluid under high pressure (approximately 19 mm.). Urine examination — 
trace of albumen ; many hyaline and finely granular caste. 

Treatment. — Although the patient was not considered a good operative 
risk owing to the condition of arteriosclerosis and chronic nephritis, yet 
it was considered the safer procedure to lessen the increasing intracranial 
pressure by the operation of subtemporal decompression and drainage than 
to allow the patient to attempt the absorption of the intracranial hemorrhage 
and cerebral edema by natural means — that is, the risk of an operation was 
less than the effect of a prolonged increase of the intracranial pressure. 

Operation (68 hours after admission) . — Left subtemporal decompression : 
usual vertical incision, bone removed and no complications; much watery 
fluid (subcutaneous edema) throughout the tissues of the scalp and temporal 
muscle. Dura exceedingly tense and upon incising it, slightly blood-tinged 
cerebrospinal fluid welled up through the dural opening, exposing a very 
' ' wet, ' ' swollen, edematous brain, which did not rupture on account of the 
rapid escape of the cerebrospinal fluid. No cortical hemorrhage nor lacera- 
tion visible. At end of operation, the cortex pulsated normally. Usual clos- 
ure with 2 drains of rubber tissue inserted. Temporary sterile dressing 
applied. The small depressed fracture just posterior to the left angular 
process of the orbit was now removed ; the dura had not been torn and was 
naturally not opened. Scalp sutured loosely with one drain of rubber 
tissue inserted. Duration, 1 hour. 

Post-operative Notes. — Within 12 hours, the patient became more con- 
scious and the pulse ascended to 80 ; within 36 hours, the signs of an increas- 
ing intracranial pressure, as revealed by the ophthalmoscope, were lessened 
so that there remained only a slight blurring of the lower nasal quadrant of 
both optic disks. Patient made an excellent operative recovery, although he 
was mildly irrational during the entire period of hospital residence ; owing to 
this emotional instability which was greater than before the injury, it was 
considered advisable to transfer him to Bloomingdale Hospital, White Plains, 
for a period of 3 months, in order that the patient should be in as ideal con- 
ditions as possible for the recovery of both mental and emotional stability. 

Examination upon transfer (40 days after injury and 37 days after 
operation). — Temperature, 99°; pulse, 88; respiration, 21; blood-pressure, 
160. Mildly irrational and excitable. Decompression area flush with sur- 
rounding scalp and pulsates normally. Pupils equal and react normally. 
Reflexes active but otherwise negative. Fundi negative. Urine examina- 
tion — trace of albumen ; many hyaline and granular casts. 

The patient remained in Bloomingdale Hospital for a period of almost 5 
months; his condition had so improved that he was able to return to his 
family and after the summer 's vacation, he was able to return to his former 
work in October, 1915 — 10 months after the injury. His condition at this 
time was considered as normal mentally and emotionally as before the injury. 



de 



ACUTE BRAIN INJURIES 393 

Examination (May 18, 1916 — 29 months after injury). — No complaints; 
patient is rather effusive, however — wife states that he always was so. De- 
compression area depressed and pulsates normally. Hearing of left ear 
impaired ; bone conduction is greater than air conduction. Reflexes active, 
but otherwise negative. Fundi negative. Urine examination — trace of 
albumen ; many finely granular and hyaline casts. 

Patient continued in this condition until November, 1917, when he died 
following an attack of pneumonia. 

Remarks. — It is doubtful whether this patient could have recovered 
unless the lessening of the increased intracranial pressure had not been 
obtained by the cranial decompression, and such an excellent recovery of the 
patient's former normality (for him) would not have been probable, if the 
increased intracranial pressure had been allowed to continue for an indefinite 
period of time; handicapped as the patient was by arteriosclerosis and 
chronic nephritis, it is difficult to conceive of the patient approximating 
his former condition to any degree. It is too much to expect that his mental 
and emotional condition could be improved by a cranial injury and such 
a benefit cannot be conceived, but if a patient is thus already impaired, the 
hope should be that the impairment is not increased by the injury, and this 
fortunate result can frequently be obtained by the early relief of the in- 
creased intracranial pressure resulting from the cranial injury. 

The presence of a watery edema in the subcutaneous tissues, as disclosed 
at operation and in the absence of an adjacent fracture of the skull with a 
tear of the underlying dura (and thus indicating the escape of the cerebro- 
spinal fluid), is usually a bad prognostic sign in that this subcutaneous 
edema usually occurs when the resistance of the patient is very much lowered 
and particularly in patients having arteriosclerosis and chronic nephritis. 
The great danger of a severe cerebral edema resulting from the cranial 
trauma in these patients and thus the risk of the early onset of an acute 
medullary compression and edema must always be feared, so that the early 
decompression and drainage is more advisable in these patients than in 
the ones who are in a better condition of resistance. 

A fracture of the skull presumably passed through the left mastoid area 
into the petrous portion of the left temporal bone, since there was a definite 
left mastoid ecchymosis and a profuse discharge of blood through a laceration 
of the left tympanic membrane ; no cerebrospinal fluid, however, was ob- 
served in this aural discharge and therefore, it cannot be stated with absolute 
certainty that a fracture of the base of the skull did occur; no fracture 
of the left squamous bone, was observed at operation, but that frequently 
happens even when there is a fracture of the left petrous bone: it is a 
rare occurrence, however, for the tympanic membrane to be ruptured indi- 
rectly by a cranial injury in the absence of a fracture of the adjacent tem- 
poral bones. The slightly depressed fracture just posterior to the angular 
process of the left orbit was of practically no importance in that the under- 
lying dura was intact and the depression was of such slight degree that it is 
doubtful if any impairment or irritation of the underlying cerebral cortex 
could have been produced by it, It is not the question of the fracture of the 
skull which is of importance, but the presence or not of a marked increase of 



394 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the intracranial pressure and that was well "taken care of" by the subtem- 
poral decompression and drainage. 

Case 91. — Acute severe brain injury associated with signs of high intra- 
cranial pressure and with a fracture of the base of the skull. Right sub- 
temporal decompression and drainage. Mental and emotional impairment. 
Excellent recovery. 

No. 971. — Frederick. Twenty-six years. White. Single. Clerk. U. S. 

Admitted November 7, 1917 — 15 minutes after injury — Nassau Hospital, 
Mineola. Referred by Doctor G. F. Cleghorn. 

Operation (November 8, 1917 — 32 hours after injury). — Right subtem- 
poral decompression and drainage. 

Discharged January 6, 1918 — 58 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Following an automobile collision, patient was thrown 
headlong to the road ; immediate loss of consciousness ; taken to the hospital 
in the automobile. Upon admission, patient was profoundly unconscious 
and in severe shock — the temperature being 97.8°, the pulse 118, while the 
blood-pressure was only 106 ; profuse bleeding from right ear and multiple 
contusions. Vigorous shock measures instituted so that the patient quickly 
recovered from the condition of shock within a period of 12 hours, and it 
was only then that the signs of an increasing intracranial pressure appeared. 

Examination (30 hours after injury; consultation with Doctor Cleg- 
horn). — Temperature, 99.8° ; pulse, 66; respiration, 18; blood-pressure, 132. 
Semiconscious and very restless — confused as to time, place and personality ; 
restraint is required to keep the patient in bed. Slight bleeding from the 
right ear ; distinct right mastoid ecchymosis. Multiple contusions over body 
and extremities. Pupils enlarged — right more than left and reaction to light 
sluggish. Reflexes — patellar very active but equal; double ankle clonus 
and double Babinski; abdominal reflexes absent. Fundi — dilated retinal 
veins; nasal halves and temporal margins of both optic disks obscured by 
edema. Lumbar puncture — bloody cerebrospinal fluid under high pressure 
(approximately 20 mm.). 

Treatment. — An immediate right subtemporal decompression advised to 
lower the intracranial pressure and to lessen the cortical irritation for fear 
of not only an acute medullary compression and medullary edema but the 
great danger of the cortical irritation becoming so great that epileptiform 
seizures would occur. 

Operation (32 hours after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed and no complications; fibres of tem- 
poral muscle were hemorrhagic and therefore a fracture of the underlying 
squamous bone was found extending obliquely downward toward the exter- 
nal auditory canal. No extradural hemorrhage but the dura itself was very 
tense and bluish, and upon incising it, bloody cerebrospinal fluid spurted to a 
height of 2 inches ; upon enlarging dural opening, a layer of supracortical 
hemorrhage of 1 cm. in thickness was exposed and evacuated; underlying 
cortex congested and edematous but no cortical hemorrhages or lacerations 



ACUTE BRAIN INJURIES 



395 



observed. At the end of the operation, the cortex pulsated normally. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Within 12 hours after operation, the signs of 
increased intracranial pressure lessened and the general condition of the 
patient improved ; patient remained, however, in a highly excitable condition, 
requiring restraint, and these signs of cortical irritability persisted for over 
7 weeks; during this period, he remained disoriented as to time, place and 
personality, babbled continuously — both sense and nonsense; the physical 
condition, however, had so improved that the reflexes had become negative 
and the fundi normal ; the decompression area was flush with the surround- 
ing scalp and pulsated normally. This mental condition was apparently 
due to the edematous condition of the brain, so that when this cerebral edema 
was absorbed at the end of 

W : - ' 






» 




7 weeks, he made an imme- 
diate improvement and was 
able to be discharged on 
January 6, 1918—59 days 
after injury. X-ray report 
— "wide irregular fracture 
of occipital bone extending 
forward toward right mas- 
toid bone; oval bone defect 
of right decompression ' ' 
(Fig. 123). 

Last Report (September 
18, 1919—22 months after 
injury) . — Patient has re- 
gained his former good 
health and is working daily ; 

no COmplamtS. FlG 123.— Lateral rontgenogram showing a linear fracture 

Remarks. It is rather °* *^ e "gh* occipital bone extending forward toward the right 

. ... mastoid area. The bony defect of a right subtemporal decom- 

UnUSlial for Cranial injuries pression, with three silver clips clamping the dural vessels, can 

t , . , , be seen. Patient has made an excellent recovery. 

to produce such a persistent 

cerebral edema and its resulting mental and emotional impairment as in 
this patient, unless the patient is beyond middle age and particularly if the 
patient is alcoholic or arteriosclerotic ; these latter patients permit a chronic 
cerebral edema to occur more easily and to persist for varying periods of 
time, but it is rare for this condition to appear in youthful adults and espe- 
cially in those of temperate habits. If it required a period of almost 2 
months for this patient to recover his mental and emotional equilibrium, 
even with a marked lessening of the intracranial pressure and consequent 
drainage of the excess cerebrospinal fluid by means of an operation, it is 
easy to conceive that, without an operation, not only would the recovery of 
life have been doubtful but even if such a recovery of life should occur, then 
the great risk of future mental and emotional impairment would have been 
very probable. Naturally, a longer period of time must elapse in the case 
of this patient before we can estimate more accurately whether there has 
been produced a permanent damage or not. 



396 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 92. — Acute severe brain injury associated with mild signs of intra- 
cranial pressure and with a fracture of base of skull. No operation. De- 
lirium tremens and cerebrospinal lues. Luetic treatment. Improved. 

No. 721. — Richard. Forty-eight years. White. Single. Laborer. U. S. 

Admitted November 11, 1916 — 50 minutes after injury — Polyclinic 
Hospital. 

Transferred to Bellevue Hospital November 26, 1916 — 15 "days 
after admission. 

Family history negative. 

Personal History. — No luetic history obtainable; chronic alcoholism, 
especially during the past 10 years. 

Present Illness. — While crossing the street, patient is said to have fallen, 
striking his head against the asphalt pavement ; an immediate general con- 
vulsion occurred, and it is not known whether the convulsion was the cause 
of the fall or the cranial injury was the cause of the convulsion ; immediate 
loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 99°; pulse, 88; respiration, 26; blood-pressure, 152. Well-developed 
and nourished. Unconscious and having general convulsions — almost the 
condition of status epilepticus. No contusion of scalp ascertained. Profuse 
bleeding and discharge of cerebrospinal fluid from the left ear; slight left 
mastoid ecchymosis. Pupils : equally contracted and reaction to light slug- 
gish; slight irregularity of the pupillary outline. Reflexes — patellar very 
much exaggerated but equal; double ankle clonus and double Babinski; 
abdominal reflexes absent. Fundi — retinal veins dilated; both retinas con- 
gested and suffused and of a brick red appearance ; both nasal and temporal 
margins rather blurred and indistinct. Lumbar puncture — bloody cerebro- 
spinal fluid under increased pressure (16 mm.). 

Treatment. — Expectant palliative. Within 12 hours after admission, the 
patient became conscious but was very irrational and mildly maniacal, 
requiring restraint ; marked tremor of both hands appeared, hallucinations 
of vision and the typical picture of delirium tremens of alcoholism developed ; 
vigorous treatment instituted and fortunately at the end of 4 days the 
patient had made such a marked improvement that restraint was no longer 
required. Pathological report of the cerebrospinal fluid was now registered 
as being 4 plus ; blood was also 4 plus, and therefore active luetic treatment 
was begun immediately. The signs of the increased intracranial pressure 
became less marked at the end of 8 days, but the patient still remained in a 
mildly irrational condition — mentally confused, disoriented as to time, place 
and personality, and emotionally unstable — crying at times and then very 
irritable. On account of the difficulty of treating a patient so affected in a 
general surgical ward, the patient was now transferred to Bellevue Hospital. 

Examination upon transfer (to Bellevue Hospital — 15 days after admis- 
sion). — Temperature, 99.2° ; pulse, 84; respiration, 24; blood-pressure, 140. 
Rather emotional, and mentally confused. Otoscopic examination revealed 
a small laceration of the upper posterior quadrant of the left tympanic mem- 
brane ; hearing tests could not be made on account of the mental condition of 
the patient. Pupils — of normal size and reaction ; pupillary margins still 



ACUTE BRAIN INJURIES 397 

irregular. Reflexes — patellar very active but equal; double exhaustible 
ankle clonus and tendency to double Babinski ; abdominal reflexes depressed 
but equal. Fundi — retinal veins enlarged ; both retinae suffused but no ede- 
matous blurring limited to the optic disks. Lumbar puncture — straw- 
colored cerebrospinal fluid under a slightly increased pressure (12 mm.). 

Last Report (May 20, 1918 — 18 months after injury.). — Patient is work- 
ing daily but is still using alcohol to excess. After being transferred to 
Bellevue Hospital, patient had remained on Blackwell 's Island for a period 
of 3 months, so that his condition was good at discharge ; while there, he 
received vigorous luetic treatment, including 7 intravenous injections of sal- 
varsan, but since leaving the hospital the patient has had no further treat- 
ment. All efforts to examine the patient have been unsuccessful so that an 
accurate knowledge of his present condition is not possible. 

Remarks. — It is rather unusual for a patient, whose resistance had been 
undoubtedly so lowered, both by chronic alcoholism and by lues, to have made 
such a comparatively excellent recovery following the cranial injury; 
patients of this type are most susceptible to brain injuries and their mor- 
tality is high in that acute cerebral edema and its resulting medullary 
compression and medullary edema occur most easily and to an extreme 
degree in this type of patient. The fracture of the skull, extending through 
the left middle ear and thereby permitting the escape of intracranial hemor- 
rhage and cerebrospinal fluid, undoubtedly afforded this patient a greater 
chance of recovery — both of life and of his former health ; the onset, however, 
of delirium tremens following so closely the cranial injury is usually a 
most dangerous factor. The general epileptiform convulsions were probably 
due to the cortical irritation of a cortical edema associated with chronic 
alcoholism and lues as the toxic factors and the cranial injury merely 
precipitated their occurrence. The comparatively excellent recovery of 
this patient is most unusual. 

The accurate measurement of the pressure of the cerebrospinal fluid is 
well illustrated in this patient; in the acute condition of cerebral edema 
and intracranial hemorrhage, the pressure as registered by the spinal mer- 
curial manometer was 16 mm., whereas at discharge and following a marked 
improvement of the patient's condition the pressure had been lessened 
to 12 mm. The lumbar puncture at the same time afforded an accurate 
means of determining the luetic status of this patient both by the AYasser- 
mann test and the cell count. 

As a routine procedure, when cerebrospinal fluid is removed at lumbar 
puncture or if the lumbar puncture has been performed primarily to meas- 
ure its pressure, a specimen of it is always sent to the laboratory for a 
Wassermann test and, in most cases, for a cell count which indicates more 
accurately the degree of activity of the process if lues is a factor ; the 
higher the cell count, the more active is the process. The condition of this 
patient would have been very confusing if a careful laboratory examination 
had not been made, and it emphasizes the importance of careful Laboratory 
tests, particularly of the cerebrospinal fluid, as a routine procedure. Then 
again, the presence of cerebrospinal lues may not have been a definite factor 
at all in the condition of this patient, although it is difficult to conceive 



398 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

that it did not tend to render the patient more susceptible to the condition 
of post-traumatic cerebral edema. 

The persistent impairment of the hearing to a marked degree is rather 
unusual in these cases of traumatic rupture of the tympanic membrane due 
to a fracture of the adjacent temporal bone — unless the condition is com- 
plicated by lues; usually the hearing improves markedly within 12 to 18 
months. The presence of lues in this patient may be a definite factor 
in preventing the recovery of the hearing ; so frequently in luetic patients 
following trauma of any part of the body, the tissue reaction and luetic 
exudate are so great and of such large amount that a complete recovery 
of the function of these tissues is prevented, and this is particularly true 
of the healing of lacerations of the tympanic membrane in that the mem- 
brane becomes unusually thickened and retracted from the new tissue 
formation; luetic treatment, however, may cause an improvement of this 
condition by facilitating its absorption. 

Case 93. — Acute severe brain injury associated with mild signs of intra- 
cranial pressure and complicated by cerebrospinal lues. No operation. 
Luetic treatment. Improved. 

No. 488. — Georgiana. Forty-two years. White. Married. Housework. 
Fnited States. 

Consultation with Doctor L. H. Finch, Amsterdam, N. Y., October 
20, 1916. 

Family history negative. 

Personal History. — One child of 18 years of age. During past 10 years, 
patient has had severe headaches which have become gradually worse; 
increasing periods of depression and melancholia. 

Present Illness. — Seventy-two hours ago, while talking to her daughter, 
patient had difficulty in making herself intelligible — used the wrong words, 
and realized it, but could not find the proper words to express her thoughts ; 
she left the room to enter the bathroom and as she stepped upon the tiled floor, 
the patient slipped, falling headlong against the bathtub ; immediate loss of 
consciousness. Three hours after injury, a general convulsion occurred 
without any localizing signs ; one hour later, another similar convulsion 
was observed, and one-half hour later the third general convulsion occurred. 
Six hours after injury, patient became semiconscious and remained in this 
stuporous condition for two days. 

Examination at consultation (October 20, 1916 — 72 hours after injury). 
— Temperature, 99.8° ; pulse, 76 ; respiration, 20 ; blood-pressure, 124. Semi- 
conscious and can be easily aroused ; complains of severe frontal headache. 
Laceration of scalp over the right eye ; careful probing reveals no fracture of 
underlying frontal bone. No signs of bleeding from nose, mouth or ears ; 
no mastoid ecchynioses. Pupils equal and react normally to light. Re- 
flexes : patellar exaggerated — left greater than right ; no ankle clonus but 
suggestive left Babinski which, however, is not constant ; abdominal reflexes 
not elicited. Fundi — retinal veins enlarged; nasal margins of both optic 
disks and nasal half of right optic disk obscured by edema. Lumbar punc- 
ture — clear cerebrospinal fluid under increased pressure (approximately 



ACUTE BRAIN INJURIES 399. 

14 mm. ) ; specimen of the cerebrospinal fluid sent to laboratory for Wasser- 
mann test and cell count. 

Treatment. — Expectant palliative. Patient continued in this semicon- 
scious condition for almost a week; the pathological report of the cerebro- 
spinal fluid was now returned as 4 plus and a cell count of 38 per c.mm. 
The immediate administration of luetic treatment — mercurial inunctions, 
potassium iodide by mouth, mercurial salicylate injections and salvarsan 
intravenously caused an immediate improvement so that within ten days 
after their administration, the patient became entirely conscious, the head- 
aches lessened and an uneventful recovery from the acute condition occurred ; 
ophthalmoscopic examination on the eighteenth day after the treatment 
began was negative. Six months after the injury, the cerebrospinal fluid 
gave only a faintly positive Wassermann reaction, whereas the cell count was 
only 16 cells per c.mm. 

Last Report (October 28, 1918 — 24 months after injury). — The patient 
is in better health than during the past 8 years. No headaches and no longer 
has periods of depression and melancholia. Physical examination negative. 
Wassermann test negative, both of blood and of cerebrospinal fluid, 
although the cell count of the latter was 12 per c.mm. 

Remarks. — It is conceivable that this patient was not only in the stage 
of cerebrospinal lues at the time of the injury, but also in that period preced- 
ing the clinical onset of possibly paresis itself. The cranial injury merely 
caused an acute cerebral edema to be superimposed upon the cerebral edema 
already present due to the luetic toxemia producing the mild condition of 
"wet" brain; any cranial injury, no matter how slight, would have precipi- 
tated this acute condition of cerebral edema and thus simulating an acute 
intracranial lesion of traumatic origin. The lumbar puncture, however, — so 
essential not only for the measurement of the pressure of the cerebrospinal 
fluid but also for the pathological report in all of these intracranial con- 
ditions — indicated the proper treatment, and the excellent result obtained 
by the luetic treatment is most gratifying. It will be necessary, however, 
to wait for a period of at least 5 years and even longer to estimate accurately 
the ultimate result. 

The greater activity of the reflexes upon the left side, and the suggestive 
left Babinski and the signs of a greater increased pressure over the right 
cerebral cortex as revealed ophthalmoscopically, indicated a greater cerebral 
edema immediately underlying the area of the direct head injury (right 
frontal region) and due most probably to an acute cerebral edema ; its corti- 
cal irritation is revealed in the epileptiform seizures which may have been 
Jacksonian in character. 



CHAPTER XI 

Post-traumatic Neuroses 

Following cranial injuries, the condition of neurosis — solely a func- 
tional impairment and in no way associated with an organic lesion or change 
of tissue — is of very common occurrence. Post-traumatic neurosis may be 
designated as being a post-traumatic neurasthenia (nerve-tire), psychas- 
thenia (mind-tire), or in general terms "a nervous breakdown"; the term 
neurosis itself is in more general use and the fact that the condition 
appears so frequently following cranial and brain injuries makes it necessary 
to discuss it briefly in a separate chapter. 

It must be stated that in many of these patients who develop an acute 
condition of nervous instability — the so-called neurosis — following cranial 
injuries of even trivial character, that a very large percentage of these 
patients were unstable emotionally for periods of months or years even 
before the accident, and that the injury itself merely precipitated and exter- 
nalized the underlying neurotic condition; the recent psycho-analytical 
methods of examination frequently reveal the predisposing causes for the 
emotional tension — domestic unhappiness, business worries, a craving for 
sympathy, etc., — so that an accident and slight injury to the body, and 
especially to the head of a patient who is already in this emotional condition, 
is sufficient in itself to be and to produce the so-called "nervous shock" — 
that is, the injury in itself was merely an immediate and contributing cause 
of the acute neurosis, which in many of these patients would have eventually 
occurred if the underlying causes of business, domestic or social worries 
had continued. 

There is, however, another factor in the production of post-traumatic 
neurosis which has commonly been overlooked ; it is the emotional influence 
upon the patient of a future lawsuit for damages as the result of the injury. 
If the accident was the alleged result of an employer 's negligence or careless- 
ness or the defendant's fault, then the emotional reaction of the patient 
(and plaintiff) is one of mingled anger and resentment — "hurt from no 
fault of my own " ; if, however, there is added to this natural reaction, which 
is in itself only a temporary one of weeks possibly, the question of a law- 
suit for damages against the offending part} 7 , then there appears imme- 
diately the complication of not only increased existing complaints but of 
many new complaints of all kinds; if the patient has had some headache 
and general soreness throughout the body, there will appear within several 
days and surely after a lawyer has been consulted regarding a lawsuit 
(if a lawyer — the so-called "ambulance chaser" — has not already secured 
the signature of the patient to an agreement for a lawsuit even while the 
patient is in bed at the hospital and within several hoursi after the injury 
and the admission) — there will then appear the added symptoms of extreme 
weakness, nausea, dizziness, restlessness and irritableness, inability to sleep, 
spells of suffocation and that vast chain of neurotic complaints. If a satis- 
factory settlement of the suit is not made within a period of several weeks 
40c 



POST-TRAUMATIC NEUROSES 401 

and the trial does not occur until about one year and even two or three years 
later, the emotional condition of the patient can easily be understood : fre- 
quent consultations with the lawyer, medical examinations of the patient 
by the defendant 's doctors, attempts to secure a satisfactory financial settle- 
ment, the finding of all the witnesses and their stories, the ordeal of a court 
trial, the date of the trial which may be postponed for months — it is thus 
easily imagined the upset condition of the patient's mind and his emotions! 
By the time the trial does actually occur, the patient is really in a highly 
neurotic condition — the emotions so sensitized that they react to the slightest 
suggestion, complaints of every character and degree are present, while 
the mind subconsciously exaggerates these symptoms to a remarkable degree ; 
their "threshold of consciousness" has 1 become so lowered to external stimuli 
as the result of the continued introspection and preparation for the trial 
which has been rehearsed to themselves daily for months, that there is no 
part of their body which does not "feel badly," and particularly is this 
true of the head; hysterical spells are not uncommon and even seizures 
simulating epileptiform convulsions of the minor (petit mal) and major 
(grand mal) types may occur in the extreme cases. 

During the past seven years, I have had an excellent opportunity of 
studying conditions of post-traumatic neurosis; associated with several 
hospitals and with an active ambulance service as maintained especially 
by the Polyclinic Hospital, I have examined in hospitals, in one week, as many 
as twelve patients having acute cranial injuries with and without a fracture 
of the skull and with and without a severe intracranial lesion. In this man- 
ner, I have been in a position to see these patients from the very beginning 
of their illness, and by a system of examining these patients once every six 
months, or at least receiving a report of their condition, it has been possible 
for me to ascertain their condition up to the present time. Of the patients 
who died in the hospital from the immediate effects of the cranial injury, 
autopsies were performed in almost every case — either by the coroner 's phy- 
sicians or by ourselves (permission having been obtained from the nearest 
relatives of the patients). The patients who recovered with and without 
operation have been repeatedly examined since their hospital residence ; law- 
suits (if these occurred) and also the present condition of the patients have 
been carefully recorded. As the hospital doctor of these patients, I have had 
an opportunity to study their conditions intimately and the results have been 
interesting as well as surprising. These patients having cranial injuries 
with and without a fracture of the skull and whether conscious, semi-con- 
scious or unconscious, in whom after their admission to the hospital there 
were found definite signs of an increased intracranial pressure as ascertained 
by the ophthalmoscopic examination of the fundi of the eyes and at lumbar 
puncture by means of the spinal mercurial manometer with and without the 
presence of blood in the cerebrospinal fluid — these were the patients having 
a distinct intracranial lesion due usually to a "wet" edematous condition 
of the brain or to a hemorrhage of varying degree associated or not with a 
cerebral laceration (which is comparatively of rare occurrence) : the patients 
in whom the intracranial pressure was high, whether there was a fracture of 
the skull or not, were operated upon to relieve this increased intracranial 
26 



402 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

pressure by the drainage of the cerebrospinal fluid and free blood and they 
formed about one-third of the patients, whereas the remaining two-thirds of 
the patients in whom the intracranial pressure was not increased or only 
mildly so, with or without a fracture of the skull, these patients were treated 
by the expectant palliative method of absolute quiet, ice-bag to the head, 
catharsis and a liquid diet until the acute signs of the injury disappeared, 
and in the majority of these latter patients in whom no blood was found 
in the cerebrospinal fluid, the signs of an increased pressure, when present, 
would fade away during the residence of the patient in the hospital — a period 
usually of one or two weeks, so that at discharge the patient could be con- 
sidered organically well. In other patients, however, the signs of a mild 
increase of the intracranial pressure would persist as demonstrated ophthal- 
moscopically by an enlargement of the retinal veins and an edematous 
blurring of the nasal margins of the optic disks; this definitely increased 
intracranial pressure in these patients was the organic cause for their head- 
ache and all of these patients had headache, dizziness, at times nausea and 
even vomiting; unless this increased intracranial pressure is gradually 
lessened by the natural means of absorption (and it usually is within a 
period of three to six months), then all of these patients develop a neurotic 
condition superimposed upon this definite organic basis resulting from the 
injury ; their symptoms are increased both in severity and in number, and 
especially if a lawsuit is contemplated and the trial is in the future; 
whether this nervous tension and emotional instability tend to elevate the 
general blood-pressure enough to prolong the intracranial condition cannot 
be ascertained, since the normal blood-pressure of these patients before 
the injury is unknown. In brief, however, it is these patients having a 
definite though mild increase of the intracranial pressure for whom the 
risk of the cranial operation of decompression and drainage would not be 
justified, and in whom this mildly increased intracranial pressure would 
ordinarily be absorbed by the natural means of absorption — it is these 
patients who do not recover their former good health and ability to work 
unless this increased intracranial pressure is eventually relieved; they 
remain "nervous" and emotionally unstable, and although usually improved 
following the trial and the end of their lawsuit, yet they are not so well as 
before the injury. 

On the contrary, however, those patients having a cranial injury, with 
and without a fracture of the skull, and especially in the absence of blood 
in the cerebrospinal fluid and in whom there are no signs of an increased 
intracranial pressure, and yet they complain, not only for weeks but for 
months following the injury, and especially if a lawsuit is pending, when 
frequently the symptoms increase both in severity and in number — these 
are the patients in whom their neurotic condition has no real organic basis, 
but it is rather due to business, domestic or social worries and most fre- 
quently of all — a lawsuit; these are the patients having a true post- 
traumatic neurosis with no underlying organic basis, who always improve 
following the successful settlement of their lawsuit — in fact, in many of 
these patients the improvement is almost immediate, so that within a week the 
patients declare that they feel almost "well again." I have seen this occur 



POST-TRAUMATrC NEUROSES 403 

over and over again : the headache practically disappears, no dizziness, no 
nausea, a sense of relief both mentally and physically, no longer easily 
fatigued — in fact, almost a new person or like their old selves; they are 
able to sleep, become less irritable and in every way much better, if not 
entirely well. If, however, the lawsuit is not satisfactorily settled — for in- 
stance, the case is appealed or the trial is postponed several months or 
even a year, then I have observed these patients to continue in their neurotic 
condition — even worse than before the first trial, and in three patients whose 
lawsuits were eventually settled satisfactorily to them, each one of them 
made an excellent recovery — and each within a period of six weeks. That is, 
in these patients having the uncomplicated condition of post-traumatic 
neurosis and naturally in the absence of a definite organic basis and espe- 
cially of an increased intracranial pressure, these patients all improve after 
the successful termination of their lawsuit, and they all make excellent 
recoveries and regain their former good health, unless even before the cranial 
injury they were emotionally unstable — and some of these patients are 
so constitutionally. One of my patients who had been knocked down by 
a taxicab and had suffered only a slight cranial injury with a small laceration 
of the scalp — this patient developed a marked neurotic condition and chiefly 
because the offending chauffeur could not be located and punished; four 
months later when the guilty chauffeur was finally arrested, the patient's 
entire nervous condition immediately improved and the neurosis lessened 
daily until two weeks later when it was ascertained that the man was a 
bankrupt — then a relapse occurred and continued for a period of five 
months when it too gradually disappeared. The patients, however, who 
have the neurosis superimposed upon a definite organic lesion such as 
a mild increase of the intracranial pressure resulting from a traumatic cere- 
bral edema of moderate degree — these patients also improve after a satis- 
factory settlement of their lawsuit but not to the extent of the former true 
neurotic patients ; unless the increased intracranial pressure ultimately 
becomes absorbed, then these patients will continue to have complaints, 
especially headache of varying degree, change of disposition to either the 
depressed or irritable and restless type, early fatigue and the other symptoms 
as well as the definite signs of a mild intracranial lesion. 

It is thus seen to be of the greatest importance, both to the patient and to 
the community, that these two conditions — a true post-traumatic neurosis 
and a definite organic lesion with a neurosis superimposed upon this organic 
basis, should be differentiated and they usually can be by careful and 
repeated neurologic examinations, and especially by competent ophthalmo- 
scopic tests and the measurement of the pressure of the cerebrospinal fluid 
at lumbar puncture by means of the spinal mercurial manometer — the most 
accurate method now known for ascertaining the presence or not of a mild 
increase of the intracranial pressure. Only too frequently the medical 
examination of these patients is a cursory and superficial one — the diagnosis 
being considered either as one of no importance at all or at most a neurosis 
(and thus favorable to the defendant), or as being a very serious condition 
of mental and physical impairment, probably of permanent duration, and 
fraught with many dangers such as epilepsy, insanity and numerous others 



4 o4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

(and all favorable to the plaintiff). It is unfortunate and lamentable that 
these patients cannot be examined by a competent medical commission — the 
patient being placed in a hospital under observation for a period of at least 
one week, careful neurologic and psychiatric examinations impartially made 
and especially the registration of the intracranial pressure — it would then 
be possible for an impartial report of the real condition to be made and 
thus eminently fair to both the patient and the def endant — and to the com- 
munity at large ; under the present system of retained doctors, these patients 
and particularly the ones having this type of conditions are notoriously mal- 
treated and misjudged — either intentionally or not. Wassermann examina- 
tion of both the blood and cerebrospinal fluid and its cell count could and 
should also be made at the time of the lumbar puncture in order to exclude 
syphilis as a factor in the condition: it occurs only too frequently that a 
trivial blow upon the head of a patient in the latent stages of neuro-syphilis 
precipitates a more active process which now appears apparently for the 
first time and progresses rapidly into the various forms of cerebrospinal 
lues and even paresis. A careful urine examination to exclude the more 
serious types of nephritic disease, diabetes and the other toxic factors of a 
chronic edema of the brain which may have existed even before the cranial 
injury or at least made it possible for a chronic cerebral edema to persist; 
cardio-vascular diseases and especially arteriosclerosis are very influential 
predisposing factors in the causation and prolongation of this cerebral 
edema. On account of the above considerations, it is of the utmost impor- 
tance that these patients should be examined very thoroughly in order to 
exclude all organic diseases in both the diagnosis and the prognosis — as well 
as to assure the appropriate treatment to the patient himself. 

It cannot be doubted that many of these patients having post-traumatic 
neuroses consciously exaggerate their symptoms to a greater or less degree, 
and almost always, subconsciously at least, during the interval between the 
cranial injury and the trial for damages, or during a period of business or 
domestic worries — the cessation of which results in an immediate improve- 
ment of the condition of the patient ; it is very easy and so natural for these 
nervous patients to ascribe any business failures and lack of capability 
to their condition of poor health — an excuse which merely permits the con- 
dition to become worse ; also in domestic unhappiness, the craving for sym- 
pathy usually tends to increase the severity and the number of the complaints. 

The more common signs frequently associated with conditions of post- 
traumatic neurosis are coarse irregular tremors and ataxia of the hands, 
a fine tremor of the eyelids upon closing the eyes and very active reflexes ; 
no Babinski reflex, however, can be elicited in any of the true cases, although 
if the neurosis is superimposed upon an organic intracranial lesion, then it is 
possible for this characteristic dorsal flexion of the big toe upon plantar 
stroking to be present; it is a most important sign, when present, in the 
differential diagnosis — it cannot be simulated successfully. Conscious 
malingering and "faking" do occur, but it is usually so palpable and obvious 
to a competent and trustworthy medical examiner that mistakes in their 
diagnosis rarely occur. 

In this connection it may not be irrelevant to mention again the com- 



POST-TRAUMATIC NEUROSES 405 

parative unimportance of the X-ray findings — unless the fracture is a 
depressed one of the vault of the skull and associated with a tear of the 
underlying dural covering of the brain. Linear fractures of the skull — vault 
or base — and not associated with a definite increase of the intracranial 
pressure are of no more significance in the treatment and the prognosis 
than that the original cranial injury was of sufficient force (and in many 
patients the blow need not be a powerful one) to cause a break in the continu- 
ity of the bone ; a linear fracture of the skull in itself does not presuppose 
and rarely indicates a serious brain injury unless associated with a high 
intracranial pressure resulting from hemorrhage or cerebral edema ; in fact, 
in many patients the fracture of the vault permits an intracranial hemor- 
rhage and an excess of cerebrospinal fluid (cerebral edema) to escape through 
the line of fracture into the subcutaneous tissues of the scalp, or of the base 
into the openings of the nose and ears, and thereby lessens an increased 
intracranial pressure so that the danger of the cranial operation of decom- 
pression and drainage is avoided and the convalescence hastened, while the 
risk of infection through the line of fracture into the nose and ears has been 
slight and not a very probable one. The exhibition in court, therefore, of 
X-ray pictures and plates of fractures of the skull should be of significance 
only in establishing the fact that a cranial injury has occurred, but whether 
the cranial injury has really caused a serious injury to the brain — that 
can only be determined by the careful and thorough neurologic and psychi- 
atric tests as outlined above. 

P0ST-TRAUMxVTIC NEUROSES 

Case 94. — Cerebral concussion ; recovery complicated by the condition of 
post-traumatic neurosis. 

No. 474.— Elizabeth. 28 years. White. Married. Clerk. United States. 

Admitted November 23, 1915. Polyclinic Hospital. 

Discharged December 8, 1915 — 15 days after injury. 

Family history negative. 

Personal History. — Usual childhood diseases. Appendiceetomy at 14 
years of age. One child 10 years of age ; 6 months before its birth, the left 
breast of the patient was removed on account of a "lump" — the size of a 
walnut ; no recurrence. 

Present Illness. — While in the lavatory of the factory in which she is 
employed, patient was struck by a marble slab of about "seven feet" in 
length, which had fallen from the ceiling upon her head; unconscious for 
several minutes and then brought by the ambulance to the hospital in a 
semiconscious condition. 

Examination upon admission (40 minutes after injury). — Temperature. 
98.2°; pulse, 88; respiration, 22; blood-pressure, 128. Well nourished 
and developed ; appendix scar is noted and the left breast is absent. Con- 
scious, but stuporous and drowsy. Complains of severe pain in head, espe- 
cially upon right side over the temporo-parietal area. No laceration of the 
scalp. No bleeding from nose, mouth or ears ; no mastoid ecchymoses. Pupils 
equal and react normally. Reflexes : active but equal ; no Babinski : abdomi- 
nal reflexes present and equal. Fundi negative. Lumbar puncture — cere- 



4 o6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

brospinal fluid perfectly clear and under normal pressure (approximately 
8 mm.). 

Treatment. — Expectant palliative. 

Examination (12 hours after admission). — Temperature, 99.4°; pulse, 
84; respiration, 20; blood-pressure, 134. Conscious; still complains of 
severe pain ' ' throughout head. ' ? No cranial eechymoses. Reflexes : patellar, 
active but equal ; no Babinski ; abdominal reflexes present and equal. Fundi 
— distinct congestion of veins of both retina? with slight blurring of nasal 
margins of optic disks, especially in right fundus. X-ray (Doctor G. W. 
Welton) — "no evidence of fracture." 

Examination (4 days after admission). — Temperature, 99°; pulse, 84, 
respiration, 22 ; blood-pressure. 136. Patient is conscious and is making 
an excellent recovery ; headaches not so severe. Reflexes : patellar, active 
but equal : no Babinski. Fundi : slight dilatation of retinal veins ; otherwise 
normal. Urine negative. 

Examination at discharge (15 days after admission). — Temperature, 
98.8°; pulse, 78; respiration, 20; blood-pressure, 132. No complaints 
except for a slight general headache and "soreness ail over." Reflexes 
negative. Fundi negative. 

Examination (May 10. 1916 — 5 months after injury). — Numerous com- 
plaints: "Headaches all of the time; dizzy spells and attacks of faintness 
so that cannot work as formerly ; unable to sleep ; no appetite ; loss of 
weight." Patient has instituted suit against the owner of the factory in 
which she was injured; is being treated by various cults — osteopaths, herb 
doctors and Christian Scientists. Pupils equal and react normally. Re- 
flexes — patellar, active but equal ; no Babinski ; abdominal reflexes present 
and equal. Fundi negative. 

Examination (February 12, 1917 — 14 months after injury). — Same 
complaints as at the previous examination in May ; headaches, however, are 
worse — ' ' driving me crazy. ' ' Reflexes — active but equal ; no Babinski. 
Fundi negative. 

Last examination (January 14, 1918 — 25 months after injury and 2 
months after the successful termination of her lawsuit from which she 
received $2800). — "Ever since Christmas (3 weeks before) I have felt 
much better; a slight headache in the morning occasionally; no dizzy or 
fainting spells ; sleep fine : good appetite and gaining in weight, ' ' Reflexes 
active but normal. Fundi negative. 

Remarks. — The almost immediate improvement occurring in this 
patient's condition upon the satisfactory settlement of her lawsuit for dam- 
ages for her injury — this result is not unusual in patients having similar 
cranial injuries and complicated by a lawsuit for damages ; if the patient 
should become well (and they rarely do) while waiting for the case to 
come to trial, the patient knows that the probability of receiving a large settle- 
ment or judgment will be lessened — and in the large majority of patients, it is 
1 ' human nature ' * for them not to ' ' get well. ' ' However, after a satisfactory 
settlement of the lawsuit, then the percentage of recovery within one year 
following the lawsuit is almost 100 per cent. Great care must be used 
by the physician in each of these patients to make the most careful and 



POST-TRAUMATIC NEUROSES 407 

thorough examinations of the patient in order to ascertain, without a question 
of a doubt, that there is no organic lesion present, before the statement 
should be made that the condition is merely a functional one — a post-trau- 
matic neurosis. Each patient should be placed in a hospital for a period 
of one week, at least, so that careful and repeated neurological examinations 
can be made, especially the reflexes tested and any sensory impairment 
elicited — whether objective or subjective, daily ophthalmoscopic examinations 
and a measurement of the pressure of the cerebrospinal fluid at lumbar punc- 
ture by means of the spinal mercurial manometer at least once and if there is 
any doubt, then the test should be repeated; a Wassermann test of the 
cerebrospinal fluid is also thus possible as well as a careful cell count. Very 
few mistakes will be made in considering true organic conditions as func- 
tional and vice versa if careful examinations are made over a period of 
one week as illustrated above. 

The neurosis of this patient was unfortunately complicated by a lawsuit, 
but the condition itself was undoubtedly prolonged and rendered less sus- 
ceptible to rational treatment by her being treated successively by osteopaths, 
chiropractics, herb doctors and last and least, Christian Scientists. 

The underlying basis of the condition in many of these patients, if the 
lawsuit is excluded, is the fear that they will ' ' go crazy ' ' as the result of the 
head injury, because a friend possibly has been sent to an insane asylum years 
after a head injury; this fear having been dispelled from many of the 
patients' minds, an immediate and marked improvement frequently occurs. 
It can be easily imagined how the condition of these patients can be aggra- 
vated if, in addition to their fears of future mental derangement, there 
should be present a feeling of resentment toward the employer as being 
the cause for the injury and that the patient is entitled to a substantial 
financial recompense : the condition would become worse rather than station- 
ary during the years following the injury and then a marked improvement 
would undoubtedly occur within a short time after a satisfactory settlement 
of the lawsuit. 

Case 95. — Severe cerebral concussion ; recovery complicated by the con- 
dition of post-traumatic neurosis. 

No. 674. — Louise. Twenty-seven years. White. Married. Actress. U. S. 

Admitted August 31, 1916, Polyclinic Hospital. 

Discharged September 17, 1916 — 17 days after injury. 

Family history negative. 

Personal History. — Appendicectomy at 7 years of age. Several attacks 
of "gall-bladder colic" during the past 10 years ; never jaundiced. 

Present Illness. — While crossing the street, patient was struck by a 
motor truck; unconscious; brought to the hospital in the ambulance. 

Examination upon admission (45 minutes after injury"). — Tempera- 
ture, 97.8° ; pulse, 104 ; respiration, 28 ; blood-pressure, 116. Well-nourished 
and developed; unconscious and in severe shock. Multiple contusions of the 
body — right side of head, shoulders, neck and chest. No bleeding from 
nose, mouth or ears; no mastoid ecchymoses. Pupils slightly dilated but of 
normal light reaction. Reflexes: patellar — very active but equal: no Babin- 
ski; abdominal reflexes can be elicited with difficulty and are apparently 



4 o8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

equal. Fundi (Dr. J. A. Kearney) — "General brick-red of entire retinae: 
veins are attenuated; margins and disks are indistinct and appear to be 
edematous — right is more marked. ' ' Urine negative. 

Treatment. — Expectant palliative; rectal enemata of hot black coffee; 
external warmth and absolute quiet to combat the shock. 

Examination (18 hours after admission). — Temperature, 99.6°; pulse, 
94; respiration, 24; blood-pressure, 128. Much better in every way. Con- 
scious ; complains of severe pain in head, right shoulder and about the ster- 
num. No mastoid nor orbital ecchymoses. Pupils negative. Reflexes — 
knee-jerks active but equal; no Babinski; abdominal reflexes present and 
equal. Fundi — slight dilatation of retinal veins and general retinal suffu- 
sion ; no definite blurring of optic disk margins. Lumbar puncture — cerebro- 
spinal fluid clear and under normal pressure (approximately 8 mm.) . X-ray 
(Doctor A. J. Quimby)' — "negative for fracture of vault or base." 

Treatment. — Expectant palliative continued; liquid diet. 

Examination (6 days after admission). — Temperature, 99.4° ; pulse, 86; 
respiration, 24; blood-pressure, 136. Irritable and restless; complains of 
severe pain ' ' all over, ' ' especially in head and chest upon deep inspiration. 
Reflexes — active but otherwise negative. Fundi — no distinct edema of the 
optic disk margins. X-ray of chest "negative for sternum and ribs." 

Examination at discharge (17 days after injury). — Temperature, 99°; 
pulse, 82 ; respiration, 24 ; blood-pressure, 132. Complains of headache and 
pain about the sternum; spells of dizziness upon arising suddenly. Com- 
plains of the negligence of the police in not locating and arresting the 
chauffeur. Reflexes active but otherwise negative. Fundi negative. 

Examination (June 20, 1917 — 10 months after injury). — Complains bit- 
terly of headache, dizzy spells and then of convulsive seizures of several 
minutes to one hour — "sudden loss of consciousness," "shaking all over" 
and frequently involuntary urination, biting of tongue and ' ' arching ' ' of the 
back; she and her husband say that these spells occur about once a week 
and usually at night. Tremor of both hands. A hospital residence of 2 days 
and examinations at this time did not disclose any abnormality or signs 
of organic disease. Reflexes active ; otherwise negative. Fundi negative. 
Lumbar puncture — clear cerebrospinal fluid under normal pressure (ap- 
proximately 6 mm.) ; Wassermann test negative and cell count was 4 cells 
per c.mm. It is now learned that the lawsuit takes place in one month ; the 
patient worries ' ' all the time ' ' about the inability of police to capture the 
offending chauffeur. 

Examination (September 12, 1917 — 13 months after injury and 2 weeks 
after close of lawsuit in which the patient received $2200). — Patient still 
complains of her pain in a general way but not so much and in such detail ; 
formerly she would recite her complaints one after the other, but now it is 
necessary to question her regarding whether she has headache, pain in her 
chest, etc.. and she always says "Yes," or "It bothers me a good deal." 
Reflexes active ; otherwise negative. Fundi negative. No longer any tremor 
of the hands. 



POST-TRAUMATIC NEUROSES 409 

Examination (April 12, 1918—20 months after injury and 6 months after 
her lawsuit). — Patient joyfully tells of her good health. "I haven't had a 
spell since the trial, although I feel light-headed sometimes." No com- 
plaints other than a sense of constriction at times about the chest upon 
exertion. ' ' The guilty chauffeur has been arrested and I now feel happy. ' ' 
Reflexes active but equal ; no Babinski. Fundi negative. 

Last Examination (September 23, 1918—27 months after injury and 
12 months after the lawsuit).— "Feel fine except my money is all gone— I 
played the ponies." Husband says there have been no spells nor other 
complaints; occasional cold in the head. Reflexes active but otherwise 
negative. Fundi negative. 

Remarks. — The condition of this patient was excellent at the time of dis- 
charge from the hospital and during the following 3 months there were few 
if any complaints, but when the possibilities of a lawsuit for damages were 
recognized, then the patient's entire condition became worse, a definite 
tremor of both hands appeared, the reflexes became more active and the 
patient developed a highly "nervous" condition. I do not wish to state that 
this patient intentionally and consciously exaggerated her symptoms and 
signs, but when she realized that it would be to her material advantage to be 
sicker than she possibly might in reality be, then she did become more ill in 
that her symptoms increased and even her signs were exaggerated — but not 
to the extent of organic disease. As soon as the lawsuit was satisfactorily 
settled, the condition of this patient rapidly improved and up to the present 
date (January 30, 1919), this patient has not had a single convulsive seizure 
(undoubtedly the former "spells" were hysterical in character) and the 
patient is a well woman in every way. I do not think this patient was 
malingering, but I do feel that both her symptoms and signs were exag- 
gerated subconsciously, due to her highly neurotic condition resulting from 
the worry incidental to a future lawsuit and the possibility of a finan- 
cial settlement. 

This patient would have been "excellent material" for the formation 
of an extreme type of post-traumatic neurosis, even if the complication 
of a lawsuit had been absent; her condition would have been aggravated 
in every way, both subjectively and objectively, and because the driver 
of the truck was not apprehended, the nervous tension of this patient was 
probably prolonged months more than if the offending chauffeur had been 
satisfactorily punished within several weeks after the injury; this patient 
would not have sympathized w T ith herself as much as she did because 
she now considered herself a sort of "martyr" and as one unjustly punished. 
I feel sure that if the offending driver had been arrested early and punished. 
she would immediately have felt better than she had for months, especially 
in the absence of a lawsuit, which prolonged the condition. In like manner, 
patients having lawsuits for damages are all benefited and feel "compen- 
sated" after a satisfactory settlement of the lawsuit. 

Case 96. — Severe cerebral concussion; recovery complicated by the con- 
dition of post-traumatic neurosis. 

No. 241. — Sadie. Twenty-five years. White. Single. Housework 
Austria-Hungary. 



410 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Admitted January 10, 1914, Polyclinic Hospital. Referred by Doctor 
Arnold Sturmdorf . 

Discharged January 31, 1914 — 21 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While the patient was walking upon the pavement in 
front of a new building which was being erected, she was struck upon the top 
of the head by a heavy wooden beam ; she was knocked down but not ren- 
dered entirely unconscious ; temporarily dazed and was led by a friend to 
the hospital. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98.8° ; pulse, 86; respiration, 26; blood-pressure, 128. Well-developed 
and nourished; complains of severe pain on top of the head and in the neck. 
Very drowsy — falling asleep while the examination was being made. Hema- 
toma over left vertex. Apparent weakness of the entire left side of face. No 
bleeding from nose, mouth or ears: no mastoid ecchymoses. Left pupil; 
possibly larger than right ; reaction to light sluggish. Reflexes : all increased 
— right more than left ; no Babinski, however, and the abdominal reflexes 
are present and equal. Fundi negative. 

Treatment. — Expectant palliative; the patient was admitted to the hos- 
pital for careful observation. 

Examination (10 hours after admission). — Temperature, 99.8°; pulse, 
84; respiration, 24; blood-pressure, 132. Conscious, very irritable and rest- 
less ; complains of terrific headache, ' ' ringing in the ears ' ' and ' ' all stiff. ' ' 
No mastoid ecchymoses. Weakness of left side of face (peripheral in type). 
Pupils — slightly dilated but equal, and react normally. Reflexes : markedly 
exaggerated but apparently equal ; no Babinski ; abdominal reflexes present 
and equal. Fundi : retinal veins enlarged— left possibly greater than right ; 
no definite blurring of nasal margins of optic disks. Lumbar puncture — 
cerebrospinal fluid clear and under normal pressure (approximately 8 
mm.). X-ray (Doctor A. J. Quimby) — "negative." 

Treatment. — Expectant palliative continued; ice helmet and effective 
catharsis apparently afford great relief to this patient. 

Examination (11 days after admission). — Temperature, 99°; pulse, 78; 
respiration, 24 ; blood-pressure, 136. Still complains of headache though not 
so severe. Sleeps most of the time and very heavily. Weakness of the left 
side of the face not so marked (the frontalis muscle being also affected, this 
condition was the peripheral type of facial paralysis and due undoubtedly 
to an edematous constriction of the left facial nerve itself) . Pupils equal and 
react normally. Reflexes : all exaggerated but no Babinski could be elicited ; 
abdominal reflexes present and equal. Fundi — slight edematous blurring 
along the nasal margins, particularly of the left optic disk; retinal 
veins enlarged. 

Examination at discharge (21 days after admission). — Temperature, 
98.8°; pulse, 80; respiration, 24; blood-pressure, 130. Headache persists; 
complains of dizziness and ' ' I feel shaky all over. ' ' Weakness of the left side 
of face can be elicited only by tests of facial movements — raising eyebrows, 
showing teeth, shutting the eyes tightly, etc., and it is only then observed 



POST-TRAUMATIC NEUROSES 411 

that the left side of the face lags slightly. Reflexes : active and equal ; no 
Babinski. Fundi — retinal veins slightly enlarged but no definite edema 
about the optic disks can be discerned. 

Examination (May 16, 1914 — 5 months after injury). — Patient com- 
plains of headache, especially in the morning, sleepiness and easily fatigued. 
Admits she is worried about her lawsuit and says she knows, "I'll feel 
better after it's all over," and — I agree with her. Pupils equal and react 
normally. Reflexes : active but equal ; no Babinski ; abdominal reflexes pres- 
ent and equal. Fundi negative ; retinal veins not enlarged. Former weak- 
ness of the left side of face cannot be elicited by any of the usual tests of 
facial movements. In order to ascertain accurately the presence or not of an 
increased intracranial pressure as a possible cause of her complaints, a lum- 
bar puncture was performed : the cerebrospinal fluid was clear and under 
normal pressure (approximately 8 mm.). 

Examination (July 15, 1914 — 7 months after injury). — Patient still 
complains bitterly of headache, sharp pain in the left eye radiating to the 
left ear, unable to work on account of drowsiness and early fatigue. Patient 
desires me to testify for her in court if necessary. No weakness of the face 
can be ascertained. Pupils — equal and react normally. Reflexes — very 
active but otherwise negative. Fundi — possibly a slight dilatation of retinal 
veins but otherwise negative. 

Examination (November 14, 1914 — 11 months after injury and 3 weeks 
after a settlement of the case out of court — patient receiving $1600). — 
Patient greeted me in the clinic of the hospital by saying, "I feel like a 
new woman since we're all through with that mess." Patient seemed 
pleased with the settlement and expressed surprise that her headaches had 
practically disappeared, except "when I stay up late"; patient has not, 
however, done any housework since she received her money. Reflexes — active 
but equal and apparently negative. Fundi negative. 

Examination (December 10, 1916 — 35 months after injury and 23 
months after the satisfactory settlement of the lawsuit). — Happily married 
and no complaints except for a pelvic condition following the birth of a child. 
Reflexes — active but otherwise negative. Fundi negative. Referred to 
Gynaecological Clinic. 

Last Examination (September 10, 1918 — 57 months after injury and 
49 months after the satisf aetory settlement of her lawsuit) . — No complaints 
except the worries of her 3 children. Occasional headache but "not bad." 
Reflexes : active but equal ; no Babinski ; abdominal reflexes not obtained 
(abdominal wall very lax and corrugated from the frequent recent preg- 
nancies). Fundi negative. 

Remarks. — The left facial weakness persisting for one month after the 
injury was undoubtedly due to a temporal edema of the left facial nerve. 
as the result of the head injury or possibly to a direct trauma to the nerve 
itself after it had left the stylo-mastoid foramen and had entered the 
posterior portion of the left parotid gland and, as all 3 branches of the nerve 
were involved, the compression of the nerve must have occurred before it 
bifurcated in the parotid gland. The usual site of the lesion producing a 
peripheral facial paralysis following head injuries is in the aqueduct of 



4 i2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Fallopius, in the petrous portion of the temporal bone as the nerve winds 
about the tympanum ; any severe injury to this part, particularly a fracture 
of the base of the skull passing through the middle fossa and into the petrous 
portion of the temporal bone, will either cause a complete tear of the facial 
nerve itself (which is rare) or an edema of varying degree of the nerve 
and thus causing its temporary compression on account of its situation in its 
narrow bony aqueduct and therefore a peripheral paralysis of more or less 
severity results; usually this edematous compression is of only temporary 
duration — as a rule, not longer than 6 weeks. If the facial paralysis is of the 
peripheral type (the forehead muscles being involved, which is a point 
of differential diagnosis from the facial paralysis of central and cortical 
origin, causing the muscles of only the lower two-thirds of the face to be 
paralyzed) and it persists for more than one year and is thus apparently 
a permanent facial paralysis, then the operation of anastomosis of one-half 
of the proximal end of the homolateral hypoglossal nerve to the entire distal 
end of the impaired facial nerve must be considered, in order to cause a 
return of motor function to the paralyzed muscles supplied by the 
facial nerve. (Vide J. A. M. A., May 11, 1918, p. 1354.) 

The vast majority of these patients are not conscious malingerers and 
they would be diagnosed as having conditions of post-traumatic neurosis, 
Avhether associated with a lawsuit or not. The effect of the lawsuit, how- 
ever, upon a patient is to change his or her attitude toward the complaints 
in that they are subconsciously exaggerated, their mind is increasingly 
directed and centered upon the complaints more and more as the trial 
approaches, a yearning for sympathy appears so that by the time the trial 
is started, the patient has reached a condition of nervous tension which may 
simulate a functional condition of almost any character, and if careful 
neurological examinations are not made it would be easy to confuse the 
condition with a definite organic disease. The trial over, and especially if 
successful from the patient's standpoint, then the relief of the nervous 
tension is great indeed and within several weeks, at most, the patient is 
enjoying excellent health! Such is the history of the large majority of 
patients having a true condition of so-called "post-traumatic neurosis." 
It is self-evident that the best treatment for these patients is a satisfactory 
settlement of the lawsuit, and no amount of medicine or psychotherapy will 
be of any marked and permanent benefit, unless the lawsuit be either satis- 
factorily settled or discontinued; I do not think it advisable to treat such 
patients medically for their neurosis while their lawsuit is still in the 
future — in the majority of patients all medical effort will be futile, and it 
is only after the lawsuit that a marked improvement is possible and — a 
satisfactory financial settlement is the panacea. 

Case 97. — Cerebral concussion; recovery complicated by the condition of 
post-traumatic neurosis. 

No. 1045. — Harry. Thirty-six years. White. Single. Iron- worker. Sweden. 

Admitted November 26, 1918 — 22 months after cranial injury, Audubon 
Hospital. Referred by Doctor W. H. Oliver. 

Discharged December 14, 1918 — 18 days after admission. 

Family history negative. 



POST-TRAUMATIC NEUROSES 413 

Personal History. — Always well and strong ; of good habits. 

Present Illness. — Twenty-two months ago (January, 1917), while patient 
was working in a factory, he was struck upon the head 1 by a large wooden 
beam ; immediate loss of consciousness for several minutes ; no bleeding from 
nose, mouth or ears ; taken to a hospital where he was discharged at the end 
of 10 days as "well." While in the hospital there were no signs of an 
increased intracranial pressure observed; the scalp had not been lacerated 
nor did there appear any orbital or mastoid ecchymoses. Patient complained, 
however, of constant dull headache, dizziness and weakness of the right side 
of body ; also numbness of both hands and feet. During the past 22 months, 
patient has been unable to work owing to these subjective complaints, and 
although he has been repeatedly examined no definite lesion has been 
ascertained. He is receiving regularly his workman's compensation. 

Examination upon admission (22 months after injury). — Temperature, 
98.6° ; pulse, 78 ; respiration, 18 ; blood-pressure 140. Well-developed and 
nourished ; looks worried and anxious. No external evidence of the former 
head injury. Patient limps slightly upon the right leg and complains of 
severe headache throughout the examination. Hearing negative ; otoscopic 
examination negative. No paralyses nor impairments of sensation elicited. 
Pupils equal and react normally. Reflexes — patellar active, right possibly 
greater than left (at a later examination this could not be confirmed) ; no 
ankle clonus nor Babinski ; abdominal reflexes present and equal. Fundi — 
retinal veins of normal size ; no edematous blurring of margins of optic disks. 
Lumbar puncture — clear cerebrospinal fluid and not under increased pres- 
sure (10 mm. as measured by the spinal mercurial manometer) ; Wassermann 
test negative and the cell count was 5 cells per c.mm. X-ray (Doctor A. J. 
Quimby) — "no fracture of the skull shown." Wassermann test of blood 
negative. Urine examination negative. The subjective weakness of the right 
hand and right leg are consciously exaggerated by the patient and all of the 
tests as to its real presence were negative ; the patient insisted that he could 
not stand with his feet together and his eyes shut, and upon being tested for it 
he was unable to do so, but later in the examination when his mind was cen- 
tered upon another test he was able to stand with his feet together and his 
eyes shut, — and perfectly. There is no nystagmus nor intention tremor, nor 
can any of the signs, including speech, of cerebellar disease be elicited ; there 
is, however, some corneal and pharyngeal hypesthesia of a hysterical charac- 
ter. During the patient ' s residence in the hospital of 18 days, the above tests 
were repeatedly confirmed. 

Diagnosis. — This condition is undoubtedly a functional one having both 
the elements of a hysterical character and of a post-traumatic neurosis com- 
plicated by the circumstances of his weekly compensation. 

Prognosis. — This is the type of patient — and there are many of them 
following head injuries of varying severity and to whom weekly or monthly 
compensation is given, — who will not recover so long as compensation (no 
matter how small) is to be obtained by these patients having complaints 
chiefly of a subjective character and of a greatly exaggerated objective 
character, either in its entirety or partially. Under the present circum- 
stances, this patient will indefinitely remain in the same condition, neither 



4 i4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

improving markedly nor becoming much worse — although the latter course 
may occur to some extent. 

Treatment. — As long as the patient receives compensation, he will not 
become well — no matter what treatment is administered, medical or surgical. 
As a matter of treatment alone, if a final settlement financially could be 
made with the patient, then an early improvement will occur — sometimes 
almost immediately, so that the patient would be able to work within a period 
of 6 months or even earlier. There is no indication of any organic disease 
intracranially and no operation would be of any benefit (even psychically) 
to this type of patient. 

Remarks. — Patients of this character are most difficult ones to treat in 
that the patient well knows that if he improves at all so that he is able to 
do light work, then his weekly or monthly compensation is diminished and 
at times, even abolished entirely. Besides, there is a marked tendency, if only 
subconsciously, for the patient under these circumstances of weekly or 
monthly compensation, to exaggerate his condition both subjectively and 
objectively — the greater the impairment, the larger the amount of compensa- 
tion. It is easily seen that to attempt to treat medically such a patient suc- 
cessfully, the question of compensation should, if possible, be settled so that it 
does not complicate the successful treatment of the patient ; in some of these 
patients a satisfactory financial settlement is the best medicine. Great care, 
however, should always be exercised by the physician in making most careful 
and thorough examinations in all of these patients before reaching the diag- 
nosis of a functional condition. 



CHAPTER XII 

Chronic Brain Injuries 

If depressed fractures of the vault are excluded, then chronic brain 
injuries are in no way dependent upon the question as to whether the skull 
has been fractured or not at the time of the cranial injury; just as in 
acute brain injuries, the presence or not of a linear fracture of the base of 
the skull is of little importance in estimating the true intracranial con- 
dition, the appropriate treatment and the prognosis, so in chronic brain 
injuries it is of little value to ascertain that a linear fracture of the skull 
has occurred at the time of the original cranial injury except as an indication 
that the injury was of sufficient force to cause a fracture of the skull ; as is 
well known, however, in many patients following a cranial injury, the skull 
may not be fractured and yet the intracranial and cerebral lesion is fre- 
quently most severe and dangerous, both to the immediate life of the patient 
and to the future normality. Naturally, cranial rontgenograms should be 
taken in all of these patients for the purpose chiefly of excluding a depressed 
fracture of the skull ; but linear fractures of the vault or of the base 
of the skull are of no diagnostic significance of the intracranial lesion — if 
one is present. The use of positive cranial rontgenograms in court as 
evidence of a permanent brain injury in these patients is more the result of 
enthusiastic ignorance than a real conception of the comparative unimpor- 
tance of the linear fractures themselves. 

In order to obtain more accurate data regarding the frequency of 
chronic brain injuries, I examined, in 1912, the records of three large hos- 
pitals in New York City of their patients having had acute brain injuries 
during the decade of 1900-1910. The average mortality from the acute 
brain injury was 50 per cent. ; of the patients who survived following opera- 
tion or no operation and were discharged as "well" or "cured," I could 
only locate 34 per cent, of them in 1912 on account of death from inter- 
current disease, change of residence, and thus "lost," etc.; of these 
34 per cent, of recoveries, however, I found that 67 per cent, of them had 
not been well since the head injury — "never the same man again," "always 
complaining," "cannot do a day's work," "queer ever since." "a bum." 
' ' a loafer ' ' and the like ; such were some of the minor complaints of both the 
former patient and the relatives — the latter observing the changes of person- 
ality following the cranial injury in a large number of the patients ; the 
complaints of "severe pain in the head," "dizzy spells" and very infre- 
quently but still an occasional patient "having convulsions" — this was 
indeed an impressive array of symptoms and also signs in two-thirds of the 
patients found, in many of whom a careful neurologic and ophthalmoscopic 
examination disclosed the definite signs of a persisting intracranial lesion. 
(At the time of these examinations in 1912, the spinal mercurial manometer 
was not in use and the importance of an accurate registration of the pressure 
of the cerebrospinal fluid in patients of this character was not fully appre- 
ciated by the medical profession.) Among these post-traumatic and chronic 

415 



4 i6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

patients, there was a number of post-traumatic neuroses either of the simple 
type associated with business, financial and domestic worries, or of the 
complicated type superimposed upon a definite organic intracranial lesion 
and usually a chronic cerebral edema of mild degree ; other patients exhibited 
increased and unequal reflexes, an occasional Babinski reflex, impairments 
of the special senses and the signs of an increased intracranial pressure as 
disclosed by the ophthalmoscopic examination of the fundi — usually an 
edematous blurring of the nasal margins and even the temporal margins 
of the optic disks, and in the absence of cardio-renal and cardio-vascular 
disease ; the factor of chronic alcoholism so common in many of these patients 
was excluded as much as possible. 

The usual intracranial lesion was apparently a chronic ' ' wet ' ' edematous 
condition of the brain following the cranial injury and due either to the 
residue of a supracortical film of hemorrhage which had not been entirely 
absorbed and thus blocking in greater or less degree the stomata of exit of the 
normal excretion of the cerebrospinal fluid into the cortical veins and sinuses, 
or to the continued presence of the acute cerebral edema immediately follow- 
ing the cranial injury but in milder degree owing to its partial but not com- 
plete absorption due to complications in the expectant method of treatment, 
such as alcoholism, intestinal and renal toxemia, mental and emotional strain 
and other harmful factors in the complete recovery of the patient. The pres- 
ence of supracortical adhesions resulting from the former subdural hemor- 
rhage was also a factor, and especially in the presence of an increased 
intracranial pressure with which they were usually associated. These findings 
were ascertained in a number of the patients at operation even at this late 
date following the acute intracranial injury and the results have been very 
beneficial in many of them. Naturally, cerebral lacerations and intracranial 
lesions destructive of brain tissue cannot be remedied and the patients are 
never operated upon unless associated with a definite increase of the intra- 
cranial pressure, which should be relieved and thus a chance for improve- 
ment is even possible in these patients by lessening the pressure upon the 
normal brain cells adjacent to the ones primarily destroyed; not only can 
the signs of impairment be improved but the symptoms of headache, dizzi- 
ness, etc., be relieved and even entirely removed. 

In brief, if depressed fractures of the vault (which should always be 
elevated or removed) are excluded, only those patients having chronic brain 
injuries associated with an increased intracranial pressure should be given 
the benefit of a subtemporal decompression in the hope and belief that a 
lessening of the increased intracranial pressure will permit a definite and 
permanent improvement, whereas those patients in whom there is no increase 
of the intracranial pressure are naturally not operated upon — no matter how 
extensive the mental or physical impairment is — since the damage in these 
patients was a primary one occurring at or due to the original brain injury, 
and the operation of cranial decompression, if indicated at any time, was 
then rather than months or years later, and especially now in the absence 
of an increased intracranial pressure. This view cannot be too strongly 
emphasized because operations are being advised in these latter patients with 
brain injuries in the absence of an increased intracranial pressure and the 



CHRONIC BRAIN INJURIES 417 

results are bad, and they cannot but be bad, since the intracranial pathology 

/cannot now be remedied. 
Traumatic Epilepsy. — The condition of post-traumaric epilepsy is a 
most discouraging one from an operative standpoint, in that it is usually 
the result of a condition which could have been relieved at the time of the 
primary cranial injury and thus the epileptiform convulsions could have 
been avoided. Naturally, depressed fractures of the vault should then be 
elevated or removed, for if permitted to remain until epilepsy of either the 
localized Jacksonian type or of the general convulsive type occurs (and it 
will occur in a large percentage of these patients), then it is frequently too 
late to obtain a good result even if the depressed area of bone or foreign body 
irritating the cerebral cortex is removed, and especially after the so-called 
epileptic "habit" (resulting from the chronic cortical irritability) has been 
established; a cranial operation at this late date will in many patients be 
followed by merely a temporary cessation of the "spells," and within a 
period of one to three years the convulsive seizures are as 1 numerous if not 
more frequent than before the operation, /in my opinion, a cranial operation 
is only indicated for those patients in whom the mental and emotional 
deterioration is slight, the epileptiform attacks few and of infrequent num- 
ber, and in whom there is disclosed a .marked increase of the intracranial 
pressure which is 1 not secondary and due to the convulsions themselves ; this 
latter differentiation can be ascertained by saturating the patient with triple 
bromides, luminal, etc., so that a convulsive seizure does not occur for a period 
of six weeks and then at the end of this non-convulsive period by estimating 
and comparing the intracranial pressure accurately by means of the oph- 
thalmoscope and the spinal mercurial manometer with the intracranial pres- 
sure as registered before this non- convulsive period. In this manner, the in- 
creased intracranial pressure, if secondary, is excluded by its return to 
normal, whereas an increased intracranial pressure which is primary to the 
convulsions can be thus ascertained definitely and by an operative removal 
of the original irritative focus, as in depressed fractures of the vault, and a 
lowering of the increased intracranial pressure in the other patients and thus 
a lessening of the cortical cerebral irritation, the patient is given in these 
selected cases a definite chance of a permanent improvement — if not, in rare 
cases, a cure itself. This careful selection of patients, both as to their general 
condition of mental and emotional deterioration, the infrequency of the con- 
vulsive seizures and the presence of a marked increase of intracranial pres- 
sure which is not secondary to the convulsions themselves (whether there is a 
depressed fracture of the skull or not) — these are the comparatively few 
patients and the only ones who can be benefited by any cranial operation of 
either an elevation or removal of the depressed area of bone or other foreign 
body or by means of the operation of cranial decompression alone. This is. 
however, late treatment of these patients — the condition should have boon 
avoided and prevented (and it usually can be at the time of the acute 
cranial injury) ; many of them become derelicts so that any treatment. 
operative or not, cannot make it possible for them to regain their former 
good health and normality, but in the selected patients as outlined above, it 
27 




* 



418 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

is not only justifiable but the only method now known of affording these ) 
patients a chance of recovery. 

A. Chronic Brain Injuries Associated with a Depressed Fracture 

of the Vault. 

In the presence of an old depressed fracture of the vault, which should 
have been elevated or removed at the time of the cranial injury if it had not 
been overlooked and not diagnosed, or (and it unfortunately happens very 
frequently — even in these more recent days) in the belief that a depressed 
fracture of the vault would not cause future impairment, because "John 
Jones had a similar depressed fracture and it did not cause trouble in his 
case" and a similar method of limited reasoning, — it is in these patients 
that merely an elevation or more usually a removal of the depressed area 
of bone, in the absence of an increased intracranial pressure, is alone suffi- 
cient to obtain a marked improvement in many of the patients — months and 
even years after the original cranial injury; in other patients, however, 
little or no improvement results ; the patient, however, should be given this 
chance of improvement. If necessary, the underlying dura may be incised 
with safety in the absence of a marked increase of the intracranial pressure 
and the supracortical or cortical cyst, with and without the presence of 
adhesions resulting from the former hemorrhage, may be incised, and the 
outer wall removed. 

In the presence of a definite increase of the intracranial pressure asso- 
ciated with the depressed fracture of the vault, then it is better surgical 
judgment to perform a subtemporal decompression first, so that the pressure 
is thus safely lowered and then the depressed area of the vault can be elevated 
or removed, and yet little or no danger to the underlying more highly devel- 
oped cerebral cortex has occurred ■ in those patients in whom the site of the 
depressed bone is overlying the large sinuses of the occipital area, it is 
frequently wiser for fear of the complications of hemorrhage not to attempt 
the local removal of the depressed bone, but to depend upon the general 
lessening of the intracranial pressure by means of the subtemporal decom- 
pression alone ; later if considered necessary, then the depressed area of bone 
may be elevated or removed. 

A. Old brain injuries associated with depressed fractures of the vault. 
No operation. Symptoms and signs persisting. Operation advisable; con- 
sent not obtained. 

Case 98. — Old brain injury associated with a depressed fracture of the 
left occipital bone ; right homonymous hemianopsia. No operation. Symp- 
toms and signs persisting. Operation advisable but refused. 

No. 161. — Clarence. Twenty-four years. White. Single. Iron-worker. 
United States. 

Admitted July 20, 1914 — 3 months after injury, Hospital for the Rup- 
tured and Crippled. Referred by Doctor W. L. Sneed. 

Discharged August 2, 1914. Operation refused. 

Family history negative. 

Personal History. — Always well and strong. Three months ago (April 16, 
1914) while at work, patient fell a distance of 35 feet from a plank, striking 



CHRONIC BRAIN INJURIES 419 

upon the back of his head; immediate loss of consciousness; taken to a 
hospital, where the laceration over the left occipital area was sutured, and 
although it was noted that there was a depressed fracture of the left occipital 
bone, no attempt was made to elevate or remove it. No bleeding from the 
nose, mouth or ears. Patient was discharged from the hospital 25 days 
after admission as "well."' He was, however, very confused mentally and 
did not remember his hospital residence or discharge ; since then he has had 
severe frontal headaches with dizziness, emotional instability and impairment 
of vision. 

Present Illness. — One day ago, patient came to hospital complaining of 
acute pain at the site of former laceration and upon examination a swelling, 
the size of an English walnut, was found at the site of former injury; it 
was incised, allowing creamy pus to escape (bacteriological report (Doctor 
Jeffries) — "staphylococci") ; it was apparently merely an infected hema- 
toma at the site of former laceration and the patient was immediately relieved 
of the local pain and tenderness. Patient, however, still complained of a 
general headache — particularly in the frontal region, dizzy spells, inability 
to "concentrate my mind," impairment of memory especially for recent 
events, and inability to see objects in the right half of the visual field. 
Brother says he is a " changed boy ' ' ; very irritable, so much so that they 
' ' fear to cross him " ; "he seems in a trance at times. ' ' 

Examination (3 months after injury — consultation with Doctor Sneed). 
— Temperature, 98.8°; pulse, 82; respiration, 18; blood-pressure, 128. 
Laceration of left occipital area bandaged ; just posterior to the left mastoid 
process is a small purulent sinus. Pupils — left contracted and reacts to light 
sluggishly ; consensual light reaction present. Reflexes — patellar very active, 
right greater than left ; no ankle clonus but tendency to a right Babinski ; 
abdominal reflexes — right depressed. Fundi — retinal veins dilated; nasal 
margins of both optic disks, and especially the left, blurred by edema; left 
physiological cup shallow from new tissue formation. Visual fields — com- 
plete right homonymous hemianopsia, otherwise fields of vision are normal 
(Fig. 124) . No nystagmus ; ocular movements normal. Lumbar puncture — 
clear cerebrospinal fluid under increased intracranial pressure (approxi- 
mately 14 mm. ) ; Wassermann reaction negative and cell count was 6 cells per 
c.mm. X-ray (Doctor B. C. Darling). — "depressed fracture of left occipital 
bone with linear fracture extending downward toward the foramen magiium. " 

Treatment. — The local infection at the site of the laceration and de- 
pressed fracture was treated by free drainage and then expectantly in the 
hope that the infection would disappear ; then if the signs of the local lesion of 
the left occipital lobe — especially the right homonymous hemianopsia, did not 
improve, it would be advisable to perform, first, a left subtemporal decom- 
pression to lessen the general increased intracranial pressure, and then a 
local exploratory procedure over the left occipital lobe in the hope that the 
lesion was one of compression rather than a primary destruction of the 
occipital cortex itself. After the local infective process subsided, however. 
the patient refused to have any further operative treatment, and the patient 
was therefore discharged in the same physical condition as upon his entrance 
with the exception of the disappearance of the local infective process. 



4 2o DIAGNOSIS AXD TREATMENT OF BRAIX INJURIES 

Examination (September IS. 1915 — 17 months after injury). — Patient 
still complains of headache, although possibly less severe than formerly ; 
unable to work at his former trade upon bridges for fear of falling in a 
"dizzy spell." Relatives state that the patient is not quite so irritable as he 
T .vas during the first 6 months following the injury : impairment of the right 
half of the field of vision persists. Laceration over the left occipital area 
entirely healed: no tenderness. Pupils unequal, left smaller than right, and 
the reaction to light is sluggish. Reflexes — patellar very active, right more 
than left: tendency to right Babinski persists: abdominal reflexes — right 
obtained with difficulty. Fundi — retinal veins enlarged : nasal margins of 
both optic disks still blurred. 

Treatment. — Even at this late date, the patient was advised to undergo. 
first, a left subtemporal decompression and then a local exploratory operation 



E. E. 



L. E. 




oerschS perimeter chart. 



....Red 
— -Blue 
- ~ Objects 



Fig. 124. — Total right homonymous hemianopsia following a depressed fracture of the left occipital bone. 
Normal consensual pupillary light reflex is present. 



with an elevation or removal of the depressed left occipital bone. The 
patient refused to have any operation performed. I Patient is receiving 
compensation each week and says: "If I die from an operation. I lose out. 
and if I get well I also lose out by losing my compensation." 

Last Report (May 18. 1918 — 49 months after injury . — Brother states 
that the patient is in practically the same condition — no better and no worse ; 
less irritable than formerly but. on the contrary, he is becoming less and less 
interested ' ' in things ' * — seldom goes out and will no longer work. Brother 
is trying to arrange for patient's admission to the hospital. 

Remarks. — It is unfortunate that an early elevation, or better, a removal 
of the depressed area of the left occipital bone was not performed, and 
if a subdural hemorrhage was present, then its early drainage : naturally, 
if there were signs of an increased intracranial pressure, then a left sub- 
temporal decompression would have been advisable first, to- be followed then 
by the local operation. 

The right homonymous hemianopsia may have been due to a laceration 



CHRONIC BRAIN INJURIES 



421 



of the left occipital cortex itself and therefore an entire recovery of the 
visual field could not be expected following an operation, and yet the 
presence of an increased intracranial pressure would encourage us to believe 
that even though the cortex itself was lacerated, yet there would be some con- 
tiguous cortical cells not primarily destroyed by the laceration but merely 
compressed and functionally impaired due to the resulting increased intra- 
cranial pressure. For this reason, in the presence of an increased intracranial 
pressure, the condition should not be considered hopeless — the hope being 
that the left occipital cortex was being compressed by the depressed area 
of bone or by an extradural or a subdural clot ; the presence of the consensual 
light reaction and its being normal, places the lesion behind the optic chiasm. 
At first, the condition was considered as possibly due to an abscess formation 
underlying the site of fracture, but the fact that the purulent discharge 
disappeared within a few days following appropriate treatment and that 
no untoward signs appeared within the following 2 years would indicate that 
the infective process had been limited to the scalp alone. 

It is to be regretted that this patient was not operated upon earlier 
when advised, as it would seem from the last reports that the patient was 
deteriorating both mentally and physically, undoubtedly due to the local 
cerebral lesion plus the increased 
intracranial pressure. 

Case 99. — Old severe brain in- 
jury associated with a penetrating 
bullet injury of the brain and with 
a mild increase of the intracranial 
pressure ; slight left hemiplegia. No 
operation; symptoms and signs per- 
sisting. Operation advisable. 

No. 287.— Ella. Twenty-one 
years. White. Single. Home. U. S. 

Admitted June 5, 1914 — 5 years 
after injury. Hospital for the Rup- 
tured and Crippled. Referred by 
Doctor B. H. Whitbeck. 

Discharged June 20, 1914 — 15 
days after admission. 

Family history negative. 

Personal History. — Always well 
and strong until cranial injury. Five 
years ago (when patient was 16 
years of age), she was accidentally 
shot twice with a .32-calibre revolver 
bullet through the right frontal 
bone near the midline and also at 
the side — the latter bullet going 

obliquely downward so that it lodged posteriorly and below the left orbit. 
whereas the first bullet remained in the right frontal lobe. Immediate 
loss of consciousness; no bleeding from nose, month or ears. Patient 




Fig. 125.— T. oft spastic hemiplegia affecting 

chiefly the left arm in a patient as the result of 
two bullet injuries of the brain. The flexor con- 
tractures of the left arm at the elbow and wrist 
are shown. 



422 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

was taken to a hospital, where she remained 4 weeks ; the wounds of entrance 
over the right vertex were carefully probed, "cleaned" and drained; 
naturally, no attempt was made to remove the bullets. Patient regained 
consciousness after five days and gradually improved so that, when she was 
discharged from the hospital, she complained only of severe headache and 
the weakness of the left side of the body. During the past 5 years, she has 
complained of continuous daily headache, but the weakness of the left side 
of the body has improved so that now the left arm is chiefly impaired. 
Patient has had competent medical treatment, massage, exercises, etc. 

Examination upon admission (5 years after injury). — Temperature, 
98.6° ; pulse, 82; respiration, 22; blood-pressure, 128. Well-developed and 
nourished. No definite mental impairment but slight emotional instability — 

irritable and unable to con- 
trol "her temper" under 
slight provocation. Over 
the right half of the 
frontal bone are the two 
scars of bullet entrance in 
the scalp. Mild left spastic 
hemiplegia, more marked in 
left arm and least in the left 
side of face; severe flexor 
contracture of left arm at 
elbow and wrist (Fig. 125) ; 
no sensory impairment can 
be elicited. Pupils — right 
slightly larger than left but 
reaction to light is normal. 
Reflexes — patellar very ac- 

Fig. 126. — Antero-posterior view showing the two bullet tive, left ULOre than right ; 

defects of entrance in the right frontal bone and the two bullets -, , ., -, , «, -. , , 

themselves— one in the right frontal lobe and the other one just exnailStlDle leit ankle ClonUS 

posterior to the left orbit. Bony and leaden particles can be „^j „ ^^~ +' i -Cl t> i • 

observed in the paths of the bullets. and suggestive leit Babm- 

ski; deep reflexes of left 
arm exaggerated; abdominal reflexes present, left less active than right. 
Fundi — retinal veins enlarged; nasal margins of both optic disks and 
nasal half of right optic disk blurred by edema. Lumbar puncture — clear 
cerebrospinal fluid under increased pressure (approximately 14 mm.) ; 
"Wassermann test negative. X-ray report — "two irregular bone de- 
fects of 1 cm. in diameter of the right half of the frontal bone; two 
bullets are clearly shown; small bony spicules are visible along the course 
of the bullets and also possibly particles of lead itself" (Figs. 126 
and 127). 

Treatment. — The presence of the definite increase of the intracranial 
pressure due most probably to a chronic cerebral edema following the 
cerebral trauma and the intracranial hemorrhage at the time of the injury, 
and since competent medical treatment has not caused a complete lessen- 
ing of the increased intracranial pressure, a right subtemporal decompres- 
sion was considered advisable to cause a cessation of the headache, possibly 





CHRONIC BRAIN INJURIES 423 

a greater ultimate improvement of the left hemiplegia and, by diminishing 
the cortical irritability, to lessen the great danger of later epileptiform 
seizures — a most serious complication. The parents of the patient felt 
that an operation was ' ' not advisable ' ' at this time and consent was there- 
fore not obtained. 

Examination (May 5, 1916 — 7 years after injury). — Patient is in practi- 
cally the same condition as at the preceding examination • the headaches 
occur daily in varying severity, while the mild left hemiplegia, particularly 
of the arm, still persists. 
Patient wishes to postpone 
operation until a later date 
so that ' ' I shall be stronger. ' ' 

Last Report (September 
10, 1918 — 9 years after in- 
jury). — Sister states that 
the patient is in the same 
condition as before but "is 
afraid of an operation." 

Remarks. — It is incon- 
ceivable that a bullet could 
penetrate the brain as in Fig 127> _ Right Iateral view of the same patient showing 

this patient and Vet there *he two bullets and the bony defects of the right frontal bone 
1 „ as the result of their entrance. 

not form a large amount of 

subdural hemorrhage and cerebral edema ; for this reason, it is always advis- 
able in the acute cases of bullet injury of the brain when the bullet has 
penetrated the dura and the cerebral tissue itself, to perform an ipsolateral 
decompression and drainage of this intracranial hemorrhage and cerebral 
edema, and thus lessen the great danger of future complications, especially 
convulsive seizures, severe headache, etc. Naturally, it is meddlesome sur- 
gery to attempt extraction of bullets and small foreign bodies which have 
penetrated the brain subcortically — the risk of causing greater cerebral 
damage is far more than the presence of the bullet itself. If the decompres- 
sion is performed, and, if necessary, a bilateral decompression and drainage, 
then the intracranial pressure will be lowered, the hemorrhage drained and 
thus the patient be given the best chance of the greatest ultimate improve- 
ment. Cerebral tissues destroyed by the passing of the bullet naturally do 
not regenerate, but the adjacent fibres and cells are merely compressed 
by edema or hemorrhage and a relief of this pressure by the subtemporal 
decompression and drainage will afford the earliest and greatest imme- 
diate and ultimate improvement, and also lessen the danger of future 
complications. 

Case 100. — Old severe brain injury associated with a depressed fracture 
of the vault and marked signs of an increased intracranial pressure ; imme- 
diate removal of the depressed area of bone. Symptoms and signs persisting. 
Decompression operation advisable. 

No. 1029. — Donald. Twenty-seven years. White, Single. Brakeman. 
England. 



4 2 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Admitted September 10, 1918 — 9 months after injury. Polyclinic Hos- 
pital. Eef erred by Doctor R. H. Dennett. 

Discharged September 18, 1918 — 8 days after admission. No operation. 

Family history negative. 

Personal History. — Always well and strong until the following cranial 
injury: 9 months ago (December 13, 1917), while at work, patient was 
caught between two freight cars and an iron bolt forced through the bone of 
the left occipital area ; no loss of consciousness ; no bleeding from nose, mouth 
or ears. Patient now remembers that he could see a little out of the left eye 
for several hours after the injury and then a gradual complete loss of vision 
of the left eye and of the temporal half of the field of vision of the right eye. 
Eight hours after the injury, the patient was operated upon at a hospital in 
Schenectady and the depressed area of bone in the left occipital region was 
removed ; the patient made an excellent operative recovery but no improve- 
ment of the vision of the left eye or of the temporal half of the field of 
vision of the right eye has occurred. During the past 8 months since the 
injury, patient has complained of persistent frontal headache, spells of 
1 1 light-headedness ' ' — at times of sufficient severity to cause him to stagger, 
but he has not fallen to the ground; tires very easily so that he has been 
unable to work throughout one whole day ; has become very irritable, espe- 
cially over trifles, and is so restless that "I can't remain in one place or do 
one thing longer than several minutes at a time ; I must then get up and go. ' ' 
Patient now comes to the hospital in the hope that something can be done 
for him so that he can "do a full day's work." No convulsive seizures, but 
he has had a momentary loss of consciousness several times, and especially 
during meal-time. 

Examination upon admission (9 months after the injury). — Tempera- 
ture, 98.6°; pulse, 70; respiration, 18; blood-pressure, 138. Unusually 
well developed and nourished (Fig. 128). No mental retardation apparent 
but a definite emotional instability — very irritable, resents questioning and 
is very restless — ' ' I must always be moving and doing something. ' ' Cranial 
examination reveals a bony defect in the lower posterior portion of the left 
parietal bone — the size of 3 cm. in diameter ; it is not depressed and pulsa- 
tion is palpable. (Apparently an osteoplastic flap operation had been per- 
formed at the time of the injury and the depressed area of the vault had 
been removed; it is not known whether the dura was opened or not.) No 
paralyses nor sensory impairments. No impairment of hearing; otoscopic 
examination of both tympanic membranes negative. Complete loss of vision 
of left eye, although patient can distinguish light but no objects; loss of 
vision of the temporal half of field of vision of the right eye ; that is, a tem- 
poral hemianopsia, of right eye (Fig. 129). Pupils — equal and react nor- 
mally, left pupil possibly slightly larger than right and its reaction to light 
not so active (this variation, however, is not constant at several examina- 
tions) ; consensual light reaction present and normal. Reflexes — patellar 
exaggerated, right more than left ; right exhaustible ankle clonus and a sug- 
gestive right Babinski ; right abdominal reflex less active than left. Fundi — ■ 
retinal veins slightly enlarged ; indistinct hazy edema about the nasal mar- 



CHRONIC BRAIN INJURIES 425 

gins of both optic disks. (Left optic disk appears smaller than normal, but no 
signs of atrophy, either primary or secondary.) Lumbar puncture — clear 
cerebrospinal fluid under increased pressure (13 mm.) ; Wassermann test 
negative, and cell count was 6 cells per c.mm. X-ray (Doctor G. W. Wei ton) 
— ' ' bony defect of irregular size and apparently of one inch in diameter in 
the lower posterior area of left parietal bone at its junction with the left 
occipital bone ; no linear fracture observed. ' ' 

Treatment. — The presence of the definite signs of an increased intra- 
cranial pressure persisting over this period of 8 months since the injury 
would indicate that a chronic cerebral edema is present and the treatment 
should be directed toward a lessening of this increased intracranial pressure 
in the hope that the condition of the patient can be improved — particularly 
the headache, the signs of cortical irritation, and thus the great danger of 
convulsive seizures be lessened ; naturally, it 
is very doubtful if the vision can be improved 
— the lesion being a central cortical one of 
the left occipital lobe and the median portion 
of the right occipital lobe due to the pene- 
tration of the iron bolt through these cere- 
bral' tissues and their optic radiations. The 
patient, therefore, was advised a non-proteid 
and non-stimulative diet (no meat, meat- 
soup, tea, coffee or alcohol), an inactive life 
with little excitement and worry, daily 
catharsis and general hygienic measures for 
a period of 3 months in the hope that the 
increased intracranial pressure would then 
be lowered. Patient was discharged with these FlG . 128 .-The normal physical appear- 
instructions on the eighth day after admission. a ^ °? thls patient contrasts strikingly 

^ with his most serious cerebral injury oJ 

Last Examinatio n ( September 1 4, 1919 the le /t occipital lobe and its characteristic 

„ . visual impairment of hemianopsia. 

12 months alter last examination and 21 

months after injury). — Patient says, "I am possibly less restless but I am 
still having trouble "; headaches persist, associated with dizzy spells and 
an occasional loss of consciousness of momentary duration; no convulsive 
seizures, however. No improvement of vision. Site of former operation 
still tense with slight pulsation palpable. The physical and neurological 
findings are practically the same as at the former examination one year ago. 
while the pressure of the cerebrospinal fluid at lumbar puncture remains 
at 13 mm. as registered by the spinal mercurial manometer. 

Treatment. — In order to lessen this increased intracranial pressure and 
thus not only improve the patient's general condition but to decrease the 
danger of convulsive seizures, a left subtemporal decompression was advised 
— even at this late date. Patient, however, refused his consent for the 
operation at this time and wants "to think it over" ; the expectant palliative 
treatment, as outlined above, was therefore continued. 

Remarks. — It is unfortunate that a left subtemporal decompression and 
drainage was not performed at the time of the removal of the depressed 
area of bone; there must have been a high intracranial pressure at that time 




426 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

due to the intradural hemorrhage and to the cerebral edema resulting from 
the cerebral trauma, and it is impossible to relieve high intradural pressure 
satisfactorily in these patients through a small dural opening at the site of 
the depressed area of bone; not only is it distinctly dangerous to attempt 
to do so for fear of operative damage to the underlying cerebral tissues and 
thus producing a definite cerebral impairment clinically, but it is impossible 
through the small dural defect to secure adequate decompression and drain- 
age — and it is impossible if the dura is not widely opened. All of these 



ForM 



^. 



1029 



I SL^JLX ^ 




£70 



EMERSONS P£RIM£TER_£HflfiT 



W a 



Fig 129.— ^Complete loss of vision of the left eye and of the temporal half of the field of vision of the 
right eye following a depressed fracture and penetrating injury in the left parieto-occipital area, indicating 
a lesion of the left occipital lobe or its optic radiations posterior to the optic chiasm to cause a right homony- 
mous hemianopsia and a lesion of the mesial surface of the right occipital lobe or of its particular optic 
radiations to cause a unilateral loss of the nasal half of the field of vision of the left eye. The consensual 
pupillary light reflex was normal in each eye. It is possible, however, that in this patient there was, in 
addition to the injury of the left occipital lobe producing the right homonymous hemianopsia, a direct 
injury to the left optic nerve which would account for the total loss of vision of the left eye (a primary 
optic atrophy); the normal consensual pupillary light reflex would then be puzzling, although it would 
be possible for it to be present. 



patients having depressed fractures of the vault and associated with marked 
signs of increased intracranial pressure should have an ipsolateral sub- 
temporal decompression first, and then the local depressed area of bone can 
be elevated, removed, and the other necessary operative procedures be accom- 
plished safely with little or no danger to the underlying cerebral cortex. 

The complete loss of vision of the left eye and of the temporal half of 
the field of vision of the right eye, particularly in the absence of a primary 
or secondary optic atrophy and in the presence of the normal pupillary 
reflex of both eyes, would indicate that the visual lesion here is a central 
cortical one of the entire left occipital lobe and of the median portion of the 
right occipital lobe — that is, the iron bolt had penetrated through the left 
occipital lobe, the falx cerebri and the median portion of the right occipital 



CHRONIC BRAIN INJURIES 427 

lobe. The existence of the normal pupillary reflex, and especially the consen- 
sual light reaction, indicates that the visual lesion must be posterior to the 
optic chiasm and thus, in this type of cranial injury, the lesion is also pos- 
terior to the corpora quaclrigemina and therefore involving the cortex of the 
occipital lobe as described above and their subcortical optic radiations. 
The necessity for the subtemporal decompression and drainage immediately 
following the injury need not be emphasized when we consider the amount 
of hemorrhage and cerebral edema which must have been associated with 
such a severe cerebral trauma ; the treatment should be similar to gunshot 
injuries of the brain when the dura has been penetrated and a direct local 
cerebral damage has resulted. The history that this patient could see out of 
the left eye for several hours following the injury is indicative of an increas- 
ing cortical hemorrhage and cerebral edema. 

It will be very interesting to follow this patient over a period of months 
and even years in order to ascertain the ultimate result — with or without 
operation. The great risk naturally is the onset of convulsive seizures, 
particularly in the presence of a definite cortical and cerebral lesion asso- 
ciated with an increased intracranial pressure ; these two factors are the 
chief causes of traumatic epilepsy and their influence should be lessened 
as much as possible — the damaged cerebral cortex cannot be regenerated, 
but the increased intracranial pressure can be lessened so that the cerebral 
cortex as a whole will be less irritable and in a more resistant condition 
and thus the onset of major convulsive seizures will be postponed and even 
entirely avoided; the spells of momentary loss of consciousness (petit mal 
attacks) can also be lessened so that they may not recur. The fact that the 
expectant palliative treatment has failed to decrease the increased intra- 
cranial pressure entirely and down to its normal level — this fact emphasizes 
the advisability of a mechanical relief of this increased intracranial pressure 
by means of a left subtemporal decompression. 

B. Chronic Brain Injuries Associated with a Fracture of the Base 

of the Skull 

It has been repeatedly emphasized in this book that it is of comparatively 
little or no importance whether the vault or the base of the skull is fractured 
or not at the time of the acute cranial injury, and this same opinion is true 
regarding the presence or not of a fracture of the base in chronic brain injur- 
ies. It is of interest in these patients for the physician to realize that the 
original trauma was of sufficient force to produce a fracture of the base of 
the skull, but this positive knowledge does not in any degree influence the 
treatment or the prognosis of conditions of chronic brain injuries. 

Of the greatest importance in these patients, however, is the presence 
or not of an increased intracranial pressure ; if present, then its lowering by 
means of the cranial operation of subtemporal decompression, which also 
permits drainage of the usual condition in these patients of a •'wet." 
edematous condition of the brain — a true chronic cerebral edema, and thus 
a permanent improvement is possible ; if there is no increase of the intra- 
cranial pressure, then there is little, if anything, that can be offered to im- 
prove the condition of these patients — the cerebral damage having already 



428 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

occurred, whether due to cortical lacerations, severe contusions, etc. Many 
of the post-traumatic conditions of these patients could have been prevented 
— if not wholly, then partially — by the proper treatment within a short time 
after the acute cranial injury, which is the ideal time to obtain the best results 
possible ; at the late date of months or years after the injury, the greatest 
possible benefit may be merely a slight improvement. 

B. Old brain injuries associated with fractures of the base of the skull. 
No operation. Symptoms and signs persisting. Operation advisable. 

Case 101. — Old severe brain injury associated with a fracture of the 
base of the skull and with signs of an increased intracranial pressure ; partial 
secondary optic atrophy. No operation. Symptoms and signs persisting. 
Operation advisable. 

No. 150. — Andrew. Thirty-seven years. White. Married. Carpenter. 
Scotland. 

Admitted March 28, 1914 — 6 months after injury. Polyclinic Hospital. 
Referred by Doctor John A. Wyeth. 

Discharged April 10, 1914 — 12 days after admission. Operation refused. 

Family history negative. 

Personal History. — Always well and strong. On September 30, 1913 
(6 months ago), scaffold upon which this patient was working collapsed and 
the patient fell a distance of 45 feet, striking upon the back of his head ; 
immediate loss of consciousness ; profuse bleeding and discharge of " watery " 
fluid from the left ear ; remained in a hospital for a period of one month. 
Since then, he has had continuous headaches, dizziness upon stooping, impair- 
ment of vision particularly of left eye, increasing irritability and faulty 
memory for recent events ; during the past month, the severity of the head- 
aches has increased so that the patient comes to the hospital for treatment. 

Examination (6 months after injury). — Temperature, 99.8°; pulse, 74; 
respiration, 18 ; blood-pressure, 130. Rather poorly nourished ; anxious 
f acies. Severe frontal and bitemporal headaches ; restless and very irritable. 
Cannot remember correctly anything that happened during the 2 years be- 
fore the accident and also since the injury. Marked tremor of both hands. 
No external signs of cranial injury. No paralysis of extremities or sensory 
impairment of any kind. Speech fair ; no definite slurring ; no aphasia or 
paraphasia. Hearing — left ear definitely impaired; Weber's test — sound 
referred always to left ear ; Rinne 's test — air conduction greater than bone 
conduction in both ears. Pupils — left larger than right and reacts to light 
sluggishly. Reflexes — patellar very much exaggerated, there being both an 
exhaustible patellar and ankle clonus; no true Babinski but no plantar 
flexion on right foot; abdominal reflexes — right more active than left. 
Fundi — retinal veins dilated; definite secondary optic atrophy — more 
marked in left eye where there persists a large amount of pigment over the 
macula lutea (the result of a former hemorrhage of the central retinal 
artery) . Visual fields — left very much contracted but concentrically. Visual 
acuity — right 9/10; left 1/100 (being almost completely blind in this eye). 
Lumbar puncture — clear cerebrospinal fluid under increased intracranial 
pressure (approximately 13 mm.) ; Wassermann test negative and cell count 
was 6 cells per c.mm. X-ray (Doctor A. J. Quimby) — ' i small linear fracture 



CHRONIC BRAIN INJURIES 429 

extending vertically downward through the left squamous bone toward the 
left mastoid area ; no other abnormalities seen. ' ' 

Treatment. — The fact that the headaches were increasing in severity and 
the presence of an increased intracranial pressure, in spite of excellent medi- 
cal treatment, would tend to make the operation of subtemporal decompres- 
sion advisable ; if after a period of 3 months, however, of most careful medi- 
cal treatment directed toward the lowering of this increased intracranial 
pressure and if it should then fail, it would be advisable to perform a 
subtemporal decompression and thereby not only lower mechanically the 
increased intracranial pressure and cause a cessation of the headache, but 
it would lessen the cortical irritability and thus the danger of convulsions 
would be avoided. Naturally, if an operation must be performed at this 
late date, it would have been much better surgical judgment to have operated 
immediately after the injury — as soon as the symptoms and signs of shock 
had disappeared and after the signs of an increased intracranial pressure 
had appeared. 

At the end of a three months' medical treatment consisting chiefly of 
general hygiene, very light diet — no meat, meat-soup, tea, coffee or alcohol in 
any form, and only small portions of fish, eggs, vegetables, milk, water (so 
that the patient was practically always hungry) , daily catharsis and warm 
"baths — in spite of this treatment the condition of the patient was practically 
the same as at the preceding examination ; a left subtemporal decompression 
was therefore advised but the patient refused his consent. 

Examination (June 20, 1916 — 33 months after injury). — Patient still 
complains of headache but not of such severity as during the year following 
the injury ; very irritable, however, so that his wife left him 8 months ago. 
Memory has improved somewhat, but "it hurts to think hard." Physical 
examination is practically the same as at the last examination except for the 
presence of a definite right Babinski and a lessening of the visual acuity 
of the right eye which is now only 6/10, whereas before it was 9/10. Patient 
is unable to work so vigorously as formerly and seems to have lost all ambi- 
tion to do so. The danger of an operation, however, is far greater, he thinks, 
than his impairments. 

Last Report (July 12, 1918 — 62 months after injury). — Sister writes 
that "Andrew has never been himself since the accident; he no longer com- 
plains as before but remains by himself ; seems stupid. ' ' 

Remarks. — An operation performed early would, I believe, have pre- 
vented the gradual and continuous mental and emotional deterioration of 
this patient ; it is very doubtful whether the vision of the left eye could have 
been benefited by an operation, as its impairment was primarily due, appar- 
ently, to a hemorrhage of the retinal artery in the left optic nerve itself: 
the visual impairment was also due to the increased intracranial pressure by 
its causing a mild secondary optic atrophy and would have been the same as 
in the right eye, which even at the last examination was only impaired to the 
extent of 6/10. The left middle ear impairment was only sufficient to lessen 
its hearing comparatively, in that the air conduction was still greater than the 
bone conduction but only to a less extent than in the right ear. 

If permission for the operation could have been obtained, it would have 



43Q DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

been very interesting to have observed this patient carefully and thns note 
any marked consequent change and improvement, so that future patients of 
the same character could be competently advised as to their treatment. 

Case 102. — Old severe brain injury associated with a fracture of the 
base of the skull and signs of an increased intracranial pressure ; convulsive 
seizures ; no operation. Symptoms and signs persisting. Operation refused. 

No. 111. — Otto. Twenty-nine years. White. Single. Clerk. Germany. 

Admitted March 1, 1915 — 4 years after injury. Polyclinic Hospital. 
Referred by Doctor E. W. Lee. 

Discharged March 11, 1915 — 10 days after admission. Operation refused. 

Family lust or y negative. 

Personal History. — Always well and strong. Four years ago, patient fell 
down the cellar stairs, landing upon his head ; immediate loss of conscious- 
ness; treated at home expectantly. Profuse hemorrhage from both ears, 
mixed with a ' ' watery fluid, ' ' ceased after 3 days ; on the sixth day after 
injury, the patient had a severe general convulsion lasting 8 minutes but no 
localizing signs were observed ; he remained in bed for 2 weeks and was able 
to work 3 weeks after injury. Since then, however, patient has had severe 
headaches and a general convulsion has occurred once a month until one 
year ago, when the convulsions ceased but the headaches continued as before. 
The treatment consisted of the usual medical and general hygienic measures. 
Two days ago, another general convulsion occurred, to be followed by a 
similar attack yesterday ; the patient walked into the hospital to obtain relief 
of headaches and to ascertain if anything could be done for the convul- 
sive seizures. 

Examination upon admission (4 years after injury). — Temperature, 
98.6°; pulse, 76; respiration. 20; blood-pressure, 128. Patient apparently 
normal except for the complaint of continuous headaches and the history of 
convulsive seizures; tongue shows several old lacerations due to its being 
bitten during the ' ' spells. ' ' No external signs of cranial injury. No motor 
or sensory impairments. Hearing negative ; otoscopic examination negative. 
Pupils equal and react normally. Reflexes — patellar very much exaggerated 
but equal; doable exhaustible ankle clonus and double suggestive Babinski; 
abdominal reflexes depressed. Fundi — retinal veins enlarged; general con- 
gestion and redness of both retinae ; nasal halves of both optic disks definitely 
obscured by edema, whereas temporal halves were fairly clear and distinct. 
Lumbar puncture — clear cerebrospinal fluid under increased pressure (ap- 
proximately 14 mm.) ; Wassermann test negative and cell count was 9 cells 
per c.mm. N-ray — "negative for fracture." 

Treatment. — Owing to the signs of increased intracranial pressure as 
shown by the ophthalmoscopic examination and the measurement of the 
cerebrospinal fluid at lumbar puncture, it was thought advisable to put this 
patient upon strict hygienic treatment with the vigorous use of triple 
bromides in the hope that the convulsive seizures could be prevented for a 
period of at least 3 months, and then if the signs of an increased pressure 
were still present, it could be fairly definitely stated that the increased 
intracranial pressure was due to a chronic cerebral edema following the 
former brain injuries (whether associated with intracranial hemorrhage or 



CHRONIC BRAIN INJURIES 431 

not), and that it was not dne to the "wet," edematous condition of the 
brain following the frequent convulsions ; that is, the increased intracranial 
pressure was a factor in causing the convulsions, and not the convulsions 
being the cause of a "wet," edematous brain and therefore the cause of 
the increased intracranial pressure — that is, the increased intracranial pres- 
sure was primary and the convulsions were secondary rather than the con- 
vulsions being primary and the increased intracranial pressure being sec- 
ondary as the result of the convulsions. 

At the end of this medical treatment for three months, however, during 
which period no convulsions had occurred, there were still present the 
signs of an increased intracranial pressure as revealed in the fundi and 
in the measurement of the pressure of the cerebrospinal fluid at lumbar 
puncture, and thus indicating that the increased intracranial pressure was 
not the result of the convulsions causing the cerebral edema but that the 
cerebral edema was a factor in producing the convulsions, which during this 
period of 3 months had been controlled by the liberal use of triple bromides. 
It was, therefore, considered advisable to advocate a subtemporal decom- 
pression as the mechanical means of lessening this increased intracranial 
pressure and thereby lower the cortical irritability, so that the convulsions 
would be less liable to occur — naturally this ' ' operation ' ' only being advised 
when the medical treatment had failed to lessen this increased intracranial 
pressure. The patient, however, considered the risk of the operation too 
great and refused; he was, therefore, put upon a strict medical treatment 
in the hope that the condition could be benefited. 

Examination (April 18, 1917 — 73 months after injury). — By the vigor- 
ous use of triple bromides and luminal, patient has been able to control the 
convulsions so that they occur only once every 2 or 3 months ; he has, how- 
ever, noticeably deteriorated both mentally and emotionally, and although. 
he is able to work, yet (as his brother states) his employers merely "toler- 
ate ' ' him in the office and he is given no responsibility. The physical exam- 
ination is practically the same as at the examination 25 months ago — the 
signs of an increased intracranial pressure being still present. 

Treatment. — After this long period of convulsive seizures it is exceed- 
ingly doubtful whether any treatment — operative or otherwise — could result 
in a "cure" of this patient; that is, the irritability of the cortex had prob- 
ably reached such a degree from the prolonged increase of the intracranial 
pressure and the other irritating factors as a result of so many preceding 
convulsions, that the formation of the so-called epileptic ' k habit" is per- 
manently established. Relatives desired the operation now but the patient 
obstinately refused "to have my head cut," 

Last Report (October 2, 1918 — 91 months after injury). — In a letter, 
brother states that the patient is in practically the same condition as at the 
last examination; works, however, now only 2 days a week and seems to be 
losing confidence in himself; no longer complains of headache; only leaves 
the house when it is absolutely necessary. 

Remarks. — This gradual mental and emotional deterioration, which 
practically always follows convulsive seizures persisting over a long period 
of time and particularly when associated with an increased intracranial 



432 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






pressure, is most pitiful to observe ; the risk of a simple decompression opera 
tion is so slight compared with the almost certain eventual mental and 
emotional deterioration that the operation is, in fact, no risk at all. Natur- 
ally, the longer the convulsive seizures have persisted in the presence of an 
increased intracranial pressure, and the more frequent and more severe the 
convulsions have become, the less hopeful is the prognosis following any 
treatment — operative or otherwise — and for this very reason an increased 
intracranial pressure complicated by convulsive seizures should be relieved 
as early as possible in order to facilitate a permanent recovery, if it can 
be obtained. 

It would seem that this patient will follow the path of other patients 
similarly affected, in that the mental and emotional deterioration will 
progress gradually — a little more each year, until the patient leads merely 
a vegetative existence so far as his usefulness to the community is con- 
cerned, and then, as the convulsions become more frequent, he thus becomes a 
greater and greater burden to his friends and relatives, and is finally com- 
mitted to an asylum where he dies eventually in the condition of status 
epilepticus or from intercurrent disease. Surely an early attempt to lessen 
the increased intracranial pressure — if medical treatment has failed — and 
thus give the patient a chance of recovery, would clearly be indicated, and 
even if in many of the older cases the ultimate end-result is the same and the 
condition would seem to have been merely delayed, yet in those patients 
treated early who do make an excellent recovery, they are thus spared this 
later institutional life and the effort is justified. 

C. Chronic Brain Injuries Associated with a Depressed Fracture of 
the Vault with Persisting Symptoms and Signs; Minor and Major 
Epilepsy. Operation. 

In the treatment of these selected patients having old depressed fractures 
of the skull and with symptoms and signs persisting, the presence or not of 
an increased intracranial pressure is of the greatest importance. If there 
is no marked increase of the intracranial pressure present, then a simple 
elevation or removal of the depressed area of bone may be, and frequently is, 
sufficient to secure a good result; if, however, there is present a definite 
increase of the intracranial pressure, then in selected patients a simple 
subtemporal decompression will suffice and the local depressed area of bone 
need not be removed, as it may not in itself be a sufficient cause of the cortical 
irritation, and especially, if it is adjacent to the longitudinal or occipital 
sinuses, its safe removal would be a difficult one technically; in other 
patients in the presence of a high intracranial pressure, it is essential in 
order to obtain an improvement at the least risk, to perform a subtemporal 
decompression first and then to elevate or remove the depressed area of 
bone. In old doubtful cases, and especially of this character, it is better 
surgical judgment to perform a subtemporal decompression first, and if a 
definite improvement does not result within a period of weeks, or, at most, 
months, then to elevate or remove the depressed area of bone which may be 
the local cortical irritant. 

C. Old brain injuries associated with depressed fractures of the vault; 



CHRONIC BRAIN INJURIES 433 

no operation; symptoms and signs persisting; minor and major epilepsy. 
Operation. Excellent recovery. 

a. Removal of depressed area of vault alone — only mild signs of an 
increased intracranial pressure being present. 

Case 103. — Old brain injury associated with a depressed fracture of 
the vault of the skull; symptoms and signs persisting. Removal of de- 
pressed bone. Excellent recovery. 

No. 110. — Charles. Thirty-eight years. White. Married. Steam-fitter. 
United States. 

Admitted March 31, 1914 — 7 months after injury. Polyclinic Hospital. 
Referred by Doctor F. N. Noble. 

Operation April 3, 1914. Removal of depressed area of bone. 

Discharged April 15, 1914 — 12 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Seven months ago while at 
work, patient was struck upon the head by a fire-brick, falling a distance 
of 8 stories ; loss of consciousness for several moments ; no bleeding from nose, 
mouth or ears; lacerated wound over the upper left occipital area. Patient 
was able to walk to a hospital where he remained 4 days and was then dis- 
charged with a sterile bandage over the laceration of the scalp ; he, however, 
was obliged to return to the hospital the same day on account of nausea and 
vomiting. He was again discharged at the end of 7 days, but since that time 
he has had continuous frontal headaches, and complains of being in a sort 
of ' ' cloud ' ' at times — dazed and drowsy ; no convulsions ; hearing of left ear 
is more impaired since the injury. Unable to work. 

Examination upon admission (7 months after injury). — Temperature, 
99°; pulse 78; respiration, 18; blood-pressure, 144. Well-developed and 
nourished. Over the left occipital area was a small sinus discharging a thin 
purulent material ; careful probing revealed a depressed fracture of the 
underlying vault. No motor or sensory impairment. Pupils equal and react 
normally. Reflexes — patellar exaggerated, right more than left ; no ankle 
clonus nor Babinski ; abdominal reflexes present and equal. Fundi — retinal 
veins dilated ; nasal margins of both optic disks blurred ; physiological cups 
of both optic disks shallow from the new tissue formation. Lumbar puncture 
— clear cerebrospinal fluid under slightly increased pressure (approximately 
11 mm.) ; Wassermann test negative and cell count was 7 cells per c.min. 
X-ray (Doctor A. J. Quimby) — "depressed fracture of left occipital bone- 
diameter about 2 cm." 

Treatment. — As the intracranial pressure was not markedly increased, 
merely a removal of the depressed area of bene was advised, both to stop the 
infective process and to prevent not only an extensive osteomyelitis but also 
a meningitis from resulting, and to lessen the danger of intradural compli- 
cations, particularly convulsive seizures. 

Operation (7 months after injury) . — Removal of depressed area of vault : 
an S-shaped incision through site of old laceration of the scalp and the dis- 
charging sinus over the left occipital bone; upon retracting the scalp, pieces 
of hair and dirt were found buried deep iu the depression and undoubtedly 
the cause of the suppuration. A comminuted depressed area of underlying 



434 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tone, the size of a silver quarter, was exposed and the depressed fragments 
removed by enlarging the bony opening with rongeurs to a size of a silver 
half-dollar; all necrosed bone was removed. Much granulation tissue upon 
the underlying dura (possibly due to a former extradural hemorrhage and 
infection) ; dura itself not tense and had not been torn, so that naturally it 
was not opened, both from the great danger of extending the infective process 
and on account of the absence of intradural pressure. Usual closure with 3 
drains of rubber tissue inserted. Duration, 25 minutes. 

Post-operative Notes. — Uneventful operative recovery ; no signs of menin- 
geal irritation occurred. 

Examination at discharge (12 days after operation). — Temperature, 
98.6°; pulse, 80; respiration, 22; blood-pressure, 142. No complaints 
except for slight soreness at the site of operation ; no headache. Wound has 
healed per primam. Reflexes — patellar very active, right still greater than 
left ; otherwise negative. Fundi — retinal veins rather full but less so than 
before operation ; blurring of nasal margins of both optic disks persists. 

Examination (June 23, 1914 — 3 months after operation and 10 months 
after injury) . — No complaints ; " as well as ever. ' ' Works daily. Operative 
wound has healed perfectly and slight pulsation palpable. Reflexes — less 
active than before and practically equal. Fundi — retinal veins enlarged 
but no definite blurring of nasal margins of either optic disk. 

Examination (December 10, 1916 — 40 months after injury). — No com- 
plaints; at work daily. Reflexes active but otherwise negative. Fundi 
negative. Operative wound is being filled in with new bone formation. 

Last Report (October 10, 1918 — 62 months after injury). — Letter from 
patient states that he is "as well as ever"; no headache, works daily. 

Remarks. — It is in depressed fractures of the vault that rontgenograms 
are most important in the treatment of cranial injuries ; even though care- 
ful palpation and, if there is an overlying laceration of the scalp, then careful 
probing, do not reveal an underlying fracture and, more important, a de- 
pressed fracture, it is then that an X-ray picture taken at the appropriate 
angle is of such valuable aid in the treatment of cranial injuries; for if 
a depressed fracture of the vault is present, then an early elevation and 
usually the removal of the depressed area of bone is necessary to lessen the 
danger of future complications — particularly an irritable cerebral cortex 
and the resulting convulsive seizures. 

In this patient, an early local operation to remove the depressed area of 
bone would very probably have prevented the infective process and thus 
the patient would have been spared the serious complication of a resulting 
osteomyelitis and even a meningitis itself. If the dura had been torn at the 
time of the injury, it is difficult to conceive how this patient could have 
escaped the serious complication of a meningitis, and therefore an early 
operative procedure is almost obligatory when there is a depressed fracture 
of the vault in the presence of an overlying laceration of the scalp. The 
absence of marked signs of intracranial pressure obviated the necessity 
of performing a subtemporal decompression first, although in doubtful cases, 
it is always the safer procedure. 

Case 104. — Old brain injury associated with a depressed fracture of the 



CHRONIC BRAIN INJURIES 



435 



& 



vault and with mild signs of an increased intracranial pressure ; symptoms 
and signs persisting. Removal of bony depression. Excellent recovery. 

No. 190. — Tom. Twenty-there years. White. Mechanic. U. S. 

Admitted December 13, 1914 — 8 months after injury. Polyclinic Hos- 
pital. Referred by Doctor John A. Wyeth. 

Operation December 15, 1914. Removal of depressed area of vault. 

Discharged December 24, 1914 — 9 days after operation. 

Family history negative. 

Personal History. — Always well and strong. While riding upon a wagon, 
patient was jolted off and fell headlong into a stone curbing; imme- 
diate loss of consciousness ; no bleeding from nose, mouth or ears ; taken to 
the Polyclinic Hospital, -_ 

where he remained until 
May 14 (16 days after in- 
jury) ; patient refused at 
that time the operation to 
elevate or remove the de- 
pressed area of the left 
frontal bone, so that only the 
laceration of the scalp over 
the left frontal area was 
sutured loosely after being 
thoroughly cleansed. Upon 
his discharge from the hos- 
pital, patient had almost 
daily headaches; no spells 
of dizziness or convulsions. 
Headaches have continued 
during the past 8 months 
associated with mild signs 
of increased intracranial 
pressure; patient is not so 
alert mentally as formerly ; a definite irritableness has also appeared during 
the past two months. 

Examination upon admission (8 months after injury). — Perfectly healed 
scar over left frontal region ; palpation reveals a definite depression of the 
underlying bone. No motor or sensory impairments. Pupils equal and 
react normally. Reflexes negative. Fundi — retinal veins rather full ; nasal 
margins of both optic disks and nasal halves of left optic disk distinctly 
blurred by edema. Lumbar puncture — clear cerebrospinal fluid under 
slightly increased pressure (approximately 11 mm.") ; AVassermann test 
negative and cell count was 4 per c.mm. X-ray (Doctor A. J. Quimby) — 
"oval depression, 2 inches in diameter, of left frontal bone; no radiat- 
ing fractures. " 

Treatment. — A local removal, or if possible, an elevation of the depressed 
area of bone advisable to prevent future complications, particularly the 
gnat danger of convulsive seizures later in life, and also to lower possibly the 
very mild increased intracranial pressure; if the increased intracranial pres- 




Fig. 130. — Huge bony defect of the left frontal bone, due to 
the removal of an extensive deoressed fracture, producing con- 
tinuous headache associated with mental retardation and emo- 
tional instability. Excellent recovery. 



436 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






sure were higher, then a subtemporal decompression would be advisable 
first, to be followed by a removal of the depressed area of bone. The 
parents were finally convinced of the necessity and really the safety of this 
operative procedure. 

Operation (8 months after injury) . — Removal of depressed area of bone : 
curvilinear incision of 2y 2 inches made over the left frontal region extending 
to the median line ; upon retracting the scalp, the underlying depression was 
ascertained and a small trephine opening made at the outer portion of the 

depressed area; an attempt to elevate 
the depressed bone was not successful, 
so that the bone itself was entirely ron- 
geured away even beyond the longitu- 
dinal sinus in the midline over which it 
extended; no complications. Underly- 
ing dura now became convex ; it was not 
markedly tense and not torn and natur- 
ally no opening was made. Usual clos- 
ure with 2 drains of rubber tissue 
inserted. Duration, 30 minutes. 

Post-operative Notes. — Uneventful 
operative recovery, so that patient was 
discharged 9 days after operation ; inci- 
sion healed per primam. X-ray picture 
discloses the bony defect of the left 
frontal area (Fig. 130). 

Examination (April 10, 1916 — 16 
months after operation). — No com- 
plaints ; works daily ; stands well in his 
class in evening school. Reflexes nega- 
tive. Fundi negative. Operative area 
slightly depressed and pulsates nor- 
mally (Fig. 131). 

Last examination (November 6, 1918 
■ — 55 months after injury and 47 months after operation). — No complaints; 
works daily and is considered a competent mechanic. Operative area slightly 
depressed and the edges are being filled in with new bone formation; only 
slight pulsation palpable. Reflexes negative. Fundi negative. • 

Remarks. — It is possible that this patient, even if no operation had been 
performed, might never have experienced any ill-effects from this bony 
depression other than possibly slight headaches ; but when we consider the 
frequency of convulsive seizures occurring in adults long after the cranial 
injury producing the bony depression in youth, and then the doubtful 
prognosis in these patients, even with an operation, there is no question 
as to the advisability of elevating and removing all depressed fractures of 
the vault for fear of future complications; once the convulsions do occur, 
then the patient can never be assured that they will cease upon the removal 
of the irritative cause. It is, therefore, commonly acknowledged that all 
depressed fractures of the vault should be elevated or removed ; the danger 




Fig. 131. — Sixteen months after the re- 
moval of a large depressed area of the left 
frontal bone, causing definite symptoms and 
signs. Excellent recovery with no complaints- 



CHRONIC BRAIN INJURIES 437 

of the operation itself is slight and as the dura need not be opened in the 
vast majority of these patients, the operation can scarcely be considered 
a major operation — in fact, it is not. 

It is rarely possible to elevate the depressed area of bone, unless in chil- 
dren and shortly after the injury ; in adults and in children after a period 
of several weeks, the depressed bone becomes so firmly "fixed" and anky- 
losed in its depressed position, that to elevate it forcibly would in most 
patients be a dangerous procedure and far more difficult than to remove it ; 
the resulting deformity is usually slight, being in most patients within the 
hair-line, and even if it does cause a noticeable depression, yet that phase 
of the condition cannot be considered an important factor ; the use of silver 
or bone plates subcutaneously is to be most strongly condemned — merely 
the insertion of possible complications. 

b. Decompression alone — there being present definite signs of an in- 
creased intracranial pressure. 

Case 105. — Old severe brain injury associated with a depressed fracture 
of the skull and with definite signs of an increased intracranial pressure ; 
convulsive seizures and hemiplegia. Right subtemporal decompression. 
Improvement. 

No. 090. — Margaret. Twenty-two years. White. Single. Maid. XL S. 

Admitted December 1, 1913 — 6 years after injury. Polyclinic Hospital. 
Referred by Doctor L. B. Rogers. 

Operation December 2, 1913. Right subtemporal decompression. 

Discharged December 10, 1913 — 8 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Six years ago while walk- 
ing along the pavement, patient was struck over the left parietal area of 
the head by a stone- tile weighing 25 pounds and falling from a height of 1 
stories ; immediate loss of consciousness ; taken to Bellevue Hospital. Forty- 
eight hours later, when patient became conscious, it was ascertained that 
the right side of body was paralyzed, associated with an incomplete motor 
aphasia; laceration of the scalp over the left parietal area was merely 
sutured. Two months after the injury, the depressed area of left parietal 
bone was elevated and within ten days there was a marked improvement 
of the right hemiplegia and speech impairment. Three years after injury 
(3 years ago), patient began having Jacksonian convulsions limited to the 
right arm, right leg and also slightly to the right side of face, but no loss 
of consciousness occurred; these convulsive seizures occurred once each 
night and at the end of 3 months, patient was again operated upon in 
Bellevue Hospital and the former depressed area of the left parietal 
bone was removed; dura, however, was not opened; after this opera- 
tion, the speech improved still more but the paralysis of the right side of 
body remained practically the same with no improvement of the convulsive 
seizures. During the past 2 years, she has complained more and more of 
continuous headaches, almost daily convulsions beginning in the right arm 
and then becoming general with loss of consciousness and of sphincteric 
control, a definite impairment of vision and increasing drowsiness so that 
the patient is no longer able to work. 



438 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



Examination upon admission (6 years after injury). — Temperature, 
98.6° ; pulse, 84; respiration, 20; blood-pressure, 134. Well-developed and 
nourished. Mental retardation and unstable emotionally. Over left parietal 
area was an irregular bony defect not larger possibly than a silver dollar ; no 
pulsation palpable. Right spastic paralysis; right heel does not touch the 
ground; no sensory impairment. Hearing negative. Mentality definitely 
clouded and the patient is emotionally dulled. Pupils equal and react nor- 
mally. Reflexes — patellar very much exaggerated, right much more active 
than left; right ankle clonus and right Babinski; abdominal reflexes de- 
pressed. Fundi — retinal veins dilated ; both optic disks rather whitish with 
irregular and shallow physiological cups; nasal margins blurred; both 

retinas suffused and con- 
gested throughout, having a 
reddish "pepper-pot" ap- 
pearance. Lumbar puncture 
— clear cerebrospinal fluid 
under a definite increase of 
pressure (approximately 16 
mm. ) ; AVassermann test neg- 
ative and cell count was 5 
cells per c.mm. X-ray (Doc- 
tor A. J. Quimby) — "irreg- 
ular bony defect of almost 2 
inches in size over upper 
left parietal area; new bone 
formation at periphery ' ' 
(Fig. 132). Definite speech 
impairment easily elicited 
by the usual speech tests — 
not a true motor aphasia but 
a paraphasia of mild degree. 
Treatment. — From the 
fact that there were still 
present definite signsi of an 
increased intracranial pres- 
sure and thus a definite organic cause for the headache and the mental and 
emotional impairments, it was considered advisable to perform a subtem- 
poral decompression to lessen this increased intracranial pressure, and 
thereby lower the cortical irritability so that the convulsive seizures might be 
decreased in number and severity ; on account of the definite increase of the 
intracranial pressure, it was thought better surgical judgment to perform a 
right subtemporal decompression rather than a left subtemporal decom- 
pression for fear of damaging the motor speech area of the left cerebral 
cortex (patient being right-handed) ; as we know, however, that the risk 
of this resulting impairment would have been practically nil, so that now 
it is realized that a left subtemporal decompression could and should have 
been performed upon this patient, as it would have lessened equally well 




Fig. 132. — Irregular bony defect (but dura unopened) of 
large diameter over the left parietal area, in a patient having 
a right hemiplegia with Jacksonian convulsive seizures. A 
marked improvement followed a subtemporal decompression. 



CHRONIC BRAIN INJURIES 439 

the general intracranial pressure and also decreased the pressure directly 
over the affected area of the left cerebral cortex much more efficiently. 

Operation (6 years after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed and no complications. Dura very tense 
and upon incising it, clear cerebrospinal fluid spurted a distance of y 2 i nc ^ — 
revealing a very ' ' wet, ' ' edematous cortex under pressure ; upon enlarging 
the dural opening, much cerebrospinal fluid escaped and thus the intradural 
pressure was quickly lessened and a rupture of the cerebral cortex was 
avoided; at the end of the operation, the brain receded and pulsated nor- 
mally. Dura was very vascular with many newly-formed vessels throughout 
so that it oozed freely. Arachnoid was very cystic with much induration 
about the vessels in the sulci. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 50 minutes. 

Post -operative Notes. — Uneventful operative recovery; incision healed 
perfectly and patient was discharged 8 clays after operation — no convul- 
sions having occurred. 

Examination (June 4, 1914 — 6 months after operation). — No convul- 
sions have occurred; occasional headache, however, and "heaviness" in 
the head upon stooping; patient says she can see better — "no longer a 
cloud present. ' ' Decompression area bulges slightly beyond flush of scalp ; 
normal pulsation visible. Spasticity of right arm and leg less marked than 
before operation; right ankle clonus and Babinski persist. Fundi — the 
signs of secondary optic atrophy are present as before operation, but the 
blurring along the nasal margins and the dilatation of the retinal vessels 
have disappeared. 

Examination (October 20, 1916 — 33 months after operation). — Patient 
had her first convulsion 10 months after the operation ; since then, she has 
had one convulsion about every 3 months. Patient no longer complains 
of headaches, however, and is able to work; impairment of speech has les- 
sened and, with the exception of the convulsions, patient has improved 
in every way. Decompression area flush with the surrounding scalp and 
pulsates normally. 

Last Report (November 2, 1918 — 59 months after operation). — Sister 
writes that patient has 1 a general convulsion every 2 to 3 months, but that 
"they no longer upset her because she can get right up and work after- 
ward." Paralysis of right arm and leg better than before the operation; 
speech also definitely improved ; only occasional headaches. 

Remarks. — The fact that the convulsive seizures have returned and even 
though they are less frequent and possibly less severe than before the 
operation, yet the fact that they have returned in spite of the lessened 
cortical irritability merely means, I fear, that the end-result of frequent 
convulsions and eventually epileptic dementia have only been delayed ; 
this was to have been expected when we consider that this patient had had 
convulsions following a depressed fracture of the skull for a period of 3 
years before the decompression operation, and that they had been so fre- 
quent as to occur daily; the presence also of a right hemiplegia indicating 
a definite damage to the underlying left hemisphere would tend to confirm 
the presence of a definite organic damage to the left cerebral cortex itself 



440 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and therefore there was present in this patient a local source of cortical 
irritation, so that even after the increased intracranial pressure had been 
relieved, there would still be a definite cause for convulsive seizures to occur. 
It would have been better surgical judgment to have performed a left sub- 
temporal decompression and exploration first, and if the local cortical irrita- 
tion could have been removed, to have done so, and thus this patient would 
have been given a still greater chance of ultimate recovery. Even if the con- 
dition of this patient was to be benefited only for a period of several years, 
yet the operation was justified both from the patient's standpoint, the 
relatives' and the community's — even in the economic factor alone. 

Case 106. — Old severe brain injury associated with a depressed fracture 
of the vault and with signs of an increased intracranial pressure ; mild left 
hemiplegia with later convulsive seizures. Right subtemporal decompres- 
sion. Improvement. 

No. 482. — Lizzie. Twenty-two years. White. Single. Operator. U. S. 

Admitted January 2, 1916 — 17 years after injury. Polyclinic Hospital. 
Referred by Doctor W. B. Pritchard. 

Operation January 10, 1916. Right subtemporal decompression. 

Discharged January 21, 1916 — 11 days after operation. 

Family history negative. 

Personal History. — When patient was 5 years of age (17 years ago), 
she fell from a second-story window, striking her head upon the ground; 
immediate loss of consciousness and paralysis of entire left side of body; 
she remained in a hospital for 6 weeks and at discharge the left arm and 
left leg were still definitely weak. Gradual improvement occurred, however, 
and the patient was considered a normal child except for a slight weakness 
and awkwardness of the left arm and left leg. Five years ago, a dull aching 
pain began in both the left arm and left leg, and one month later, frontal 
and occipital headaches occurred almost daily and have continued with 
increasing severity and frequency up to the present time, so that she has been 
unable to work during the past year ; during the past 12 months she has had 
7 general convulsive seizures with loss of consciousness. 

Examination upon admission (17 years after injury). — Temperature, 
98.6°; pulse, 80; respiration, 22; blood-pressure, 128. Well-developed and 
nourished. Over the right parietal area is a slight irregular bony depression 
extending downward below the attachment of the right temporal muscle 
to the parietal crest. Slight weakness of both the left arm and left leg, 
as demonstrated by the hand-grip and by testing the strength of each leg ; 
left leg quickly becomes tired after walking several blocks or after standing 
a few minutes. No sensory impairment. Hearing negative. Mentality — 
definite retardation and emotionally unstable — very irritable and ' ' loses her 
temper" upon the slightest provocation. Pupils equal and react normally. 
Reflexes: patellar — left greater than right; exhaustible left ankle clonus 
and absence of left plantar reflex with a tendency to a left Babinski ; 
abdominal reflexes — left difficult to elicit. Fundi — retinal veins slightly 
enlarged; lower nasal quadrants of both optic disks indistinct and both 
nasal margins slightly blurred and irregular from new tissue formation; 
right physiological cup shallow. Lumbar puncture — clear cerebrospinal 



CHRONIC BRAIN INJURIES 44^ 

fluid under increased pressure (20 mm.) ; Wassermann test negative and 
cell count was 5 cells per c.mm. X-ray (Doctor W. H. Stewart)— "definite 
periostitis over right parietal bone, which was slightly depressed for an area 
of almost 3 inches in diameter, extending down to the right squamous bone." 

Treatment. — The definite signs of an increased intracranial pressure as 
revealed both by the ophthalmoscope and by the lumbar puncture, the 
presence of a distinct bony depression of the right vault associated with a 
weakness of the left arm and left leg, and the history of persistent headaches 
and of their increasing severity and, during the past year, of several 
epileptiform seizures in spite of the routine medical treatment, it was there- 
fore considered advisable to perform a right subtemporal decompression 
in the hope that a lessening of this increased intracranial pressure would 
cause a definite improvement — even though the injury had been of such 
long duration. 

Operation (17 years after injury). — Right subtemporal decompression-, 
usual vertical incision, bone removed and no complications; the temporal 
muscle, however, contained a large amount of connective tissue, due undoubt- 
edly to a former hemorrhage in its fibres ; the bone at the upper portion of the 
opening was thickened and vascular, as though a fracture had been present 
in this area. Dura rather whitish and tense, and upon incising it clear 
cerebrospinal fluid spurted a distance of one-half inch, and upon enlarging^ 
the dural opening a large amount of cerebrospinal fluid escaped, allowing the 
underlying bulging cortex to recede and pulsate normally. Cortex very 
' ' wet ' ' and edematous, with a whitish induration along the vessels in the sulci 
— the evidence of a former subarachnoid hemorrhage ; no gross lesion of the 
brain ascertained, and as the depressed area of bone above was very slight, 
it was decided not to remove it in the belief that a simple decompression 
would suffice. Usual closure with 2 drains of rubber tissue inserted. Dura- 
tion, 45 minutes. 

Post-operative Notes. — The operative recovery was uneventful; within 
3 days after operation, the headaches lessened and at the time of discharge — 
11 days after operation — no convulsions had occurred ; the incision healed 
per primam. 

Examination (April 10, 1917 — 15 months after operation). — Patient has 
improved in every way so that she has been able to work during the past 
6 months; only an occasional headache and but 3 convulsions since the 
operation — the last one being 4 months ago and of a very light character, 
hardly more than that of petit mal. Decompression area slightly de- 
pressed and pulsates normally. Definite improvement of use and strength 
of left arm and left leg. Reflexes — patellar increased, left more than right ; 
no ankle clonus and distinct plantar flexion (normal) ; abdominal reflexes 
present and equal. Fundi — retinal veins of normal size ; no definite blur- 
ring of nasal margins of optic disks but the presence of the new tissue 
formation naturally persists. Rontgenogram reveals the decompression 
opening with three silver clips in situ (Fig. 133). 

Last Report (August 21, 1918 — 31 months after operation ). — Patient 
writes that she is in good health, works daily, and has no complaints other 
than a dull headache about once a mouth, and particularly at the time of 



442 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



her menstruation; has only had one "light spell" during the past 10 
months ; to her friends, her left arm and left leg are the same as her right 
arm and right leg in that her gait is normal, although patient says herself, 
"I know there is a difference between them." 

Remarks. — The favorable factor in this case is that, although the cranial 
injury was of many years' duration, yet the convulsive seizures did not 
occur until one year before the operation — that is, 16 years after the injury, 
and at the time of the operation only 7 convulsions had been observed ; the 
prognosis, therefore, for this patient is more hopeful and a complete recov- 
ery from the convulsive seizures may be obtained. It would appear that these 
convulsions had been due to the increased intracranial pressure of a chronic 
cerebral edema which aggravated the cortical irritation due to the former 

subarachnoid hemorrhage 
and, therefore, by simply 
lessening this increased 
intracranial pressure by a 
subtemporal decompression, 
a marked improvement was 
obtainable. The bony de- 
pression of the vault was of 
such a slight extent that an 
ipsolateral decompression 
was alone necessary. The 
definite improvement of the 
left hemiplegia and the early 
cessation of the headaches 
are most impressive. It will 
be necessary, however, to 
wait for a period of at least 
5 years before estimating the 
permanent benefit of the 
operation. 

It is difficult to explain 
the mild left hemiplegia 
unless we consider it as having been due originally to a film of supracortical 
hemorrhage following the cranial injury associated with a depressed fracture 
of the overlying vault ; as this subdural and subarachnoid blood was gradu- 
ally absorbed by natural means, the left hemiplegia improved until only the 
mild signs of it remained ; as the result of the depressed fracture of the bone 
overlying the right cerebral motor cortex and the persistence of a chronic 
cerebral edema, especially of this same area of the brain, the signs of a mild 
left hemiparesis could still, years later, be elicited by special tests, so that a 
mere right subtemporal decompression was sufficient in itself to obtain a 
marked improvement. Naturally, if there had been a lesion of this cerebral 
cortex sufficient to destroy and impair permanently the cortical nerve cells, 
then it would have been impossible for an improvement of marked degree to 
occur in that the cortical nerve cells do not regenerate ; fortunately, however, 
in the majority of patients the intracranial lesion following brain injuries 




Fig. 133. — Oval bony defect of right subtemporal decompres- 
sion in a patient having an increased intracranial pressure with 
persisting symptoms and signs following a cranial injur y. Marked 
improvement. Three silver clips upon the meningeal vessels 
can be seen in the bony defect. 



CHRONIC BRAIN INJURIES 443 

is usually one of compression from hemorrhage and edema to the degree 
only of functional impairment, and not a destruction or impairment of 
permanent character. 

Case 107. — Old severe brain injury associated with a depressed fracture 
of the left parietal area of the vault and with signs of an increased intra- 
cranial pressure ; right hemiplegia and spells of petit mat. Left subtemporal 
decompression. Improvement. 

No. 24. — Hilda. Twenty-one years. White. Single. Clerk. Germany. 

Admitted February 4, 1915 — 19 years after injury. Hospital for the 
Ruptured and Crippled. Referred by Doctor Virgil P. Gibney. 

Operation March 26, 1915. Left subtemporal decompression. 

Discharged April 19, 1915 — 24 days after operation. 

Family history negative. 

Personal History. — Third child, 9 months' pregnancy, normal labor 
with no instruments being used ; apparently a normal child until the cranial 
injury. When patient was 18 months of age (19 years ago), she fell from 
a third-story window, striking upon the left side of her head; immediate 
paralysis of entire right side of body; remained unconscious for 6 days 
with profuse bleeding and discharge of cerebrospinal fluid from the left 
ear ; gradually recovered so that the patient apparently developed normally, 
both mentally and physically, with the exception of a slight stiffness and 
weakness of the right arm and right leg ; no convulsions at any time. Patient 
left school at the age of 14 years and was able to work as a clerk, always 
using the left arm in preference to the right arm (both parents, however, and 
her brothers and sisters were all right-handed). Six months ago, patient 
noticed that her occasional headaches were increasing in frequency and 
severity ; and at the same time the right hand became weaker and the right 
leg felt "heavy and stiff,' 7 so that a definite lameness of the right leg 
appeared. Three months ago, she became aware of a slight weakness 
of the left hand and left arm so that her penmanship became more and more 
difficult; it was then that her first "fainting spell" occurred while the 
patient was eating — loss of consciousness of not more than 10 seconds' dura- 
tion, but sufficient to be observed by the other members of the family. Since 
this time and during the past 3 months, she has had several lapses of 
consciousness {petit mal attacks), the headaches have increased while the 
stiffness and weakness of the arms and legs have become more and more 
marked until she came to the hospital for treatment. 

; Examination upon admission (19 years after injury). — Temperature, 
98.6°; pulse, 84; respiration, 24; blood-pressure, 130. Well-developed and 
nourished. Over the left parietal bone is a depressed area of almost 
3 inches in diameter as ascertained by palpation. Marked right spastic 
hemiplegia, right arm being affected more than the right leg : only slight right 
facial weakness — elicited by special tests alone. No sensory impairment. 
Hearing of left ear not so acute as that of right ear; air conduction, however. 
is greater than bone conduction in both ears. Mentally — slight retardation 
and loss of initiative ; emotionally of the depressed type, sluggish and 
"happy go lucky" (as her sister expressed it) ; since the onset of the attacks 
of momentary losses of consciousness (spells of petit man, patient has been 



444 DIAGNOSIS AXD TREATMENT OF BRAIN INJURIES 



confused mentally, her memory impaired, especially for recent events, and 
"in many ways a changed girl.'' Patient remained in the hospital for 51 
days, during which time she was repeatedly examined and her condition care- 
fully observed. Pupils equal and react normally. Reflexes — patellar very 
much exaggerated, right more than left ; inexhaustible right ankle clonus and 
right Babinski ; inconstant left Babinski ; abdominal reflexes — right difficult 
to elicit. Fundi — retinal veins enlarged ; nasal margins of both optic disks 
blurred, left more than right ; disk margins themselves rather irregular 
from new tissue formation. Lumbar puncture — clear cerebrospinal fluid 
under increased pressure (approximately 16 mm.) ; Wassermann test nega- 
tive : cell count was 5 cells per c.nrm. X-ray — ' ' over the left parietal area of 
the vault are two wide lines of fracture with a distinct depression of about 

2y 2 inches in diameter and 
extending down to the left 
parietal crest*' (Fig. 134). 

Treatment. — The pres- 
ence of the signs of an in- 
creased intracranial pressure 
associated with a definite 
right hemiplegia which has 
become worse even with com- 
petent medical treatment, 
during the past 6 months 
since the onset of severe 
headaches and spells of petit 
inal. made a left decompres- 
sion operation advisable even 
at this late date following 
the original brain injury; 
naturally, it would seem 
that an operation should 
have been performed at the 
time of the injury rather than at this late date. 

Operation (19 years after injury). — Left subtemporal decompression: 
usual vertical incision, bone removed and no complications: bone was un- 
usually thick, almost one cm., and very vascular. Dura thickened, whitish 
and under high tension ; upon incising it, a small amount of cerebrospinal 
fluid escaped, and upon enlarging dural opening, the underlying cortex 
appeared almost like liver tissue, in that it was filled with multiple punctate 
hemorrhages and having a supracortical bluish cystic formation (it would 
seem that this condition was of shorter duration than our history would indi- 
cate — 19 years since the cranial injury). Sufficient cerebrospinal fluid 
escaped, together with the evacuation of the straw-colored fluid of the 
bluish subarachnoid cysts, to permit the cortex to bulge less tensely and to 
pulsate normally at the end of the operation. L'sual closure with 2 drains 
of rubber tissue inserted. Duration. 50 minutes. 

Post-operative Xotes. — Uneventful operative recovery; spasticity of right 




Fig. 134. — Two wide linear fractures of left vault in a patient 
who had received a cranial injury at eighteen months of age, 
with a resulting right hemiplegia and epileptiform spells. Defi- 
nite improvement following a left subtemporal decompression. 



CHRONIC BRAIN INJURIES 445 

arm lessened within one week following operation and even on the fourth 
day post-operative, patient was able to extend the fingers of right hand 
"more than ever in my life"; incision healed per primam. 

Examination at discharge (24 days after operation). — Temperature, 
98.8° ; pulse, 76 ; respiration, 22 ; blood-pressure, 132. No headache and the 
"heavy feeling" in the head has almost entirely disappeared. Marked 
improvement of the spasticity of the right arm and the right leg. No spells 
of petit mal type since operation. Decompression area flush with the sur- 
rounding scalp. Reflexes — patellar exaggerated, right more than left; 
inexhaustible right ankle clonus and right Babinski still persist; abdom- 
inal reflexes — right less active than left. Fundi — retinal veins enlarged; 
nasal margins more distinct than before operation, though the newly formed 
tissue about the optic margins naturally is present. 

Examination (January 10, 1917 — 23 months after operation and 21 years 
after injury). — Patient has made a marked improvement: right hemiplegia 
has lessened though it is still present; an occasional dull headache while 
the spells of petit mal have only occurred 9 times during the past 2 years. 
She is able to work daily and is now using her right hand to perform 
simple acts; she has more "ambition" according to sister. Decompres- 
sion area slightly depressed. Reflexes — patellar exaggerated, right more 
than left; inexhaustible right ankle clonus and right Babinski; abdom- 
inal reflexes — right less active than left. Fundi — retinal veins slightly 
enlarged ; nasal margins, however, of both optic disks distinct though irregu- 
lar from newly formed tissue. 

Last Report (October 10, 1918 — 43 months after operation). — Sister 
writes that patient is now living out West and that her condition has not 
improved since last examination one year ago; she had, however, only 
3 spells of petit mal during the past year and was ' ' sufficiently well " to be 
married 2 months ago. She no longer complains of headaches and ' ' seems 
to be enjoying life. ' ' 

Remarks. — The pathology as revealed at operation was of such an exten- 
sive character and in the cortex itself that the ultimate prognosis must be 
considered very grave, even in spite of this definite improvement following- 
operation. Naturally, the chief danger lies in the formation of the so-called 
epileptic "habit" due to the cortical irritation as the result of the cortical 
hemorrhage; this process undoubtedly has been retarded by the lessening 
of the increased intracranial pressure by means of the decompression, but it 
seems too much to expect an ultimate cure to be effected. 

There must have been in this patient a destruction of some of the cortical 
nerve cells due to the multiple punctate hemorrhages among them, but that 
other of the cortical nerve cells had been merely compressed by these punc- 
tate hemorrhages and the resulting cerebral edema, so that when the in- 
creased intracranial pressure was finally lessened by means of the decompres- 
sion (even at the late date of years following the original injury), these 
compressed cells functionally were now enabled to regain their former activ- 
ity to a greater or less degree and thus an almost immediate improvement ot' 
the patient's condition appeared. Naturally, this lessening of the increased 



446 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

intracranial pressure by means of the decompression should have been 
performed years ago — better at the time of the original injury. 

It is surprising how well children under 2 years of age and even older, 
apparently recover following severe cranial injuries; unfortunately, how- 
ever, it does happen rather frequently that a child entirely recovers only 
clinically, and if more careful and thorough examinations were made at the 
time of the injury and over a period of weeks and even months following 
the injury, it could be very easily ascertained whether there were intracranial 
signs present indicative of future complications — particularly the presence 
or not of an increased intracranial hemorrhage ; in those children in whom 
the increased intracranial pressure is high following the injury, although 
they apparently make an excellent recovery from the acute condition, yet 
it is in these children that future complications occur, such as mental retarda- 
tion and emotional instability and epileptiform seizures of major and minor 
character. Their history is so frequently that of being considered normal 
children, even until the age of puberty when the cortical nerve cells develop 
qualitatively, as it were, and it is then that the definite signs of impairment 
appear, and so frequently associated with convulsive seizures of varying 
degree. All children having severe cranial injuries should be considered 
as being seriously injured until repeated thorough examinations, particu- 
larly with the ophthalmoscope and the measurement of the cerebrospinal 
fluid at lumbar puncture, as registered by means of the spinal mercurial 
manometer; naturally, exhaustive neurological examinations are essential. 

Case 108. — Old severe brain injury associated with a depressed gun- 
shot fracture of the vault and with signs of an increased intracranial pres- 
sure ; removal of depressed bone alone and insertion of silver plate ; convul- 
sive seizures. Right subtemporal decompression and removal of silver 
plate. Improvement. 

No. 1047. — Paul. Eighteen years. White. Single. Soldier. Russia. 

Admitted November -24, 1918 — 39 months after injury. Audubon Hos- 
pital. Referred by Doctor James A. Harrar. 

Operation December 5, 1918 — 11 days after admission. Right subtem- 
poral decompression. 

Discharged December 24, 1918 — 19 days after operation. 

Family history negative. 

Personal History. — Always well and strong until the present cranial in- 
jury. On August 28, 1915 (39 months ago), while fighting as a private 
soldier in the Russian army in Galicia, patient was struck over the posterior 
portion of the right fronto-parietal area near the midline by a shell frag- 
ment, producing a depression of the underlying bone ; he was found uncon- 
scious and taken to an advanced emergency hospital, where the depressed 
area of bone was removed and a metal plate inserted beneath the scalp within 
24 hours after the injury; he remained unconscious for 3 days, having 
a paralysis of the entire left side of the body, which began to improve, 
however, 6 days after operation ; he remained in the hospital 4 weeeks, but 
the wound did not heal until 14 months later, owing to a purulent discharge 
from the posterior portion. In October, 1915 (2 months after injury), 
patient had his first general convulsive seizure — no localizing signs being 



CHRONIC BRAIN INJURIES 447 

observed; in December, 1915 (4 months after injury), the second general 
convulsive seizure occurred and at this time it was noted that the left arm 
and left leg convulsed first, and then the right side of the body was involved ; 
patient complained of continuous dull headache. The third convulsion was 
in May, 1916 (9 months after injury), and the last convulsive seizure 
occurred in September, 1918 (2 months ago), following a bicycle-ride; no 
localizing signs were observed. During these past 3 years since the injury, 
patient has complained almost daily of dull headache. He has, however, 
improved in every way — there being no gross sign present of the former 
left hemiplegia. Father states that the patient is not so alert mentally 
as formerly, and is emotionally unstable — flying into fits of anger upon 
slight provocation. 

Examination upon admission (39 months after injury). — Tempera- 
ture, 98.8°; pulse, 78; respiration, 22; blood-pressure, 134. Unusually 
well-developed and nourished. Patient spoke only Russian, so that it was 
impossible to elicit the mental retardation as stated by the father ; patient was 
very restless, however, and very irritable as illustrated by his throwing a glass 
of drinking water at a nurse for not being more attentive to him. Over the 
posterior portion of the right parietal area was a curvilinear scar of 4 inches 
in length ; the underlying bone was irregular but no marked depression pal- 
pable. No paralysis nor sensory impairments. Hearing negative ; otoscopic 
examination negative. Pupils equal and react normally. Reflexes — patellar 
exaggerated, left possibly more active than right; no ankle clonus but sug- 
gestive left Babinski ; abdominal reflexes present and equal. Fundi — retinal 
veins enlarged ; nasal margins of both optic disks blurred by edema ; physio- 
logical cups' both shallow from new tissue formation. Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (16 mm.) ; Wassermann 
examination negative and cell count was 5 cells per c.mm. Urine examina- 
tion negative. X-ray (Doctor A. J. Quimby) — "dense circular shadow over 
the right fronto-parietal area of the size of 3 inches in diameter — most prob- 
ably a silver plate covering an underlying bony defect" (Fig. 135). 

Treatment. — The history of the cranial injury with subsequent convul- 
sive seizures — the last one being 2 months ago, and associated with definite 
signs of an increased intracranial pressure with mental and emotional im- 
pairment, these facts make advisable a lessening of this increased intra- 
cranial pressure by means of a right subtemporal decompression in the hope 
that the condition will be improved ; also the irritation of the foreign body 
over the right cerebral cortex should be removed. This patient has been 
under competent medical treatment during the past 2 years at least. 

Operation (39 months after injury). — Right subtemporal decompression : 
usual incision, bone removed and no complications ; an unusual amount of 
bleeding owing to the vascularity of the scalp, muscle and of the bone itself ; 
a branch of the right middle meningeal artery was torn by the rongeurs so 
that it required ligation by means of a silver clip. Dura tense, opaque, 
thickened and very vascular; upon incising it, clear cerebrospinal fluid 
spurted to a height of 3 inches, and upon enlarging the dural opening, a 
large bluish cystic mass was exposed, lying in and upon the underlying cortex 
— the C} r stic residue of a former supracortical ami cortical hemorrhage: 



448 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




large dilated cortical vessels passed through it, and upon incising it carefully, 
a straw-colored fluid welled out to the amount of almost 1 ounce. So much 
cerebrospinal fluid escaped that the intradural tension was lessened and 
the cerebral cortex receded and pulsated almost normally. Much fibrous 
induration in the arachnoid, and particularly about the cortical vessels in 
the sulci — the residue of a former subarachnoid hemorrhage. Vertical 
incision now enlarged upward and the silver plate easily removed ; many 
dural adhesions to it. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 60 minutes. 

Post-operative Notes. — Uneventful operative recovery; the dull heavy 
feeling of the head lessened and at the end of one week, the patient told his 

father that his headache 
had gone; patient was dis- 
charged on the sixteenth 
day after operation; inci- 
sion healed per primam; 
operative area pulsates 
normally. 

Last Report (September 
12, 1919—10 months after 
operation). — Father states 
that the patient has made 
a marked improvement in 
that no convulsive seizures 
have occurred, the head- 
aches have entirely dis- 
appeared and the patient 
is more stable emotionally; 
he is studying engineering 
in England and has become 
very much interested in his 
work; "it is now possible 
for him to learn, whereas 
before he could not concen- 
trate his mind upon any- 
thing. " Operative area does not bulge beyond the flush of scalp. 

Remarks. — The fact that this patient had had only 4 convulsive seizures 
since the cranial injury of over 3 years ago is very encouraging from the 
standpoint of prognosis, and yet the pathological lesion of a hemorrhagic 
cyst as disclosed at the operation and its being in the cortex and not merely 
upon the cortex, as is usually the case, makes the ultimate recovery from 
the convulsions verj 7 doubtful; the removal of the silver plate, however, 
may be very beneficial. It is most unfortunate that this operative procedure 
of decompression and drainage was not performed within a short time 
following the injury rather than at this late date, when only the pressure 
effects of this hemorrhage and the resulting cerebral edema can be lessened 
and offset, whereas following the injury upon the patient 's recovery from the 
shock, the operation of subtemporal decompression and drainage would have 




Fig. 135. — Large silver plate inserted over bony defect of 
right fronto-parietal area and causing definite symptoms and 
signs. Its removal and the lowering of the increased intra- 
cranial pressure by a right subtemporal decompression has 
caused a marked improvement. 



CHRONIC BRAIN INJURIES 449 

drained off the hemorrhage itself and thus an excellent result have been 
obtained and no convulsive seizures probable ! Merely elevating or removing 
the depressed bone of the vault (besides the insertion of foreign bodies for 
"protection") and not relieving the increased intracranial pressure when 
associated with intradural hemorrhage and marked cerebral edema, — this 
method of treatment is not sufficient and these traumatic sequelae of de- 
pressed fractures of the vault are only too common following the local 
operation upon the depressed area of bone alone. 

The supracortical hemorrhage must have been very large and extensive 
to have produced a complete left hemiplegia; its gradual absorption, how- 
ever, so that the hemiplegia has practically disappeared, would indicate that 
the pathology as disclosed at the operation may now be limited to this 
comparatively silent area of the right temporo-sphenoidal lobe, and naturally 
the clinical signs of its presence cannot be elicited — other than the signs 
of a general increase of the intracranial pressure and the slight neurological 
changes. Naturally, it will be necessary for a number of years to elapse 
before an opinion regarding this patient's ultimate recovery can be given. 

c. Two operations: decompression first, then removal of the depressed 
area of vault — there oeing present definite signs of a marked increase of the 
intracranial pressure. 

Case 109. — Old severe brain injury associated with a depressed fracture 
of the vault and with signs of an increased intracranial pressure ; convulsive 
seizures. Two operations: left subtemporal decompression first, and then 
a removal of the depressed area of bone. Improvement. 

No. 115. — Joseph. Fourteen years. White. School. XL S. 

Admitted March 1, 1914 — 7 years after injury. Polyclinic Hospital. Re- 
ferred by Doctor M. Allen Starr. 

Operations April 2, 1914. Left subtemporal decompression and removal 
of depressed area of vault. 

Discharged April 10, 1914 — 8 days after operations. 

Family history negative. 

Personal History. — Always well and strong until cranial injury. Seven 
years ago, when patient was 7 years of age, he was kicked by a horse over 
the posterior portion of the left frontal area ; no loss of consciousness ; patient 
was taken to a hospital in the ambulance and a ' ' bone pressing on the brain 
was removed"; upon his discharge from the hospital 3 months later, it 
was noticed that the right leg was much weaker than the left and that its 
movements were more awkward; also "his mind, seemed to be in a cloud." 
This condition continued until 2 years ago (patient then being 12 years of 
age), when the first general convulsive seizure occurred — no localizing signs 
being observed; he had been complaining of headache which now became 
much worse. Four weeks later, the second general convulsive seizure 
occurred, to be followed by similar convulsions with increasing frequency and 
severity until it was necessary, 7 months ago, to place the patient in an insti- 
tution. During these past 7 months in the institution, he has complained of 
persistent headaches, convulsive seizures have occurred almost daily and 
the personality of the patient has entirely changed, in that now he has 
sudden fits of anger associated with wanton cruelty — being a danger and 
29 



45o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

menace to other children, even necessitating his isolation and restraint 
at times. 

Examination npon admission (7 years after injury). — Temperature, 
98.6°; pulse, 80; respiration, 22; blood-pressure, 124. "Well-developed and 
nourished. Over the posterior portion of left frontal bone is a depressed area 
of 1% inches in diameter ; no pulsation palpable. Patient seems confused 
mentally, retarded and in a very irritable condition. Hearing negative. 
Pupils equal and react normally. Reflexes : patellar — right more active than 
left; no ankle clonus nor Babinski; abdominal reflexes present and equal. 
Fundi — retinal veins dilated; nasal halves of both optic disks obscured by 
edema ; much new tissue formation about optic disk margins and in physio- 
logical cups, making* both optic disks rather pale and thus giving the appear- 
ance of a mild secondard optic atrophy. Lumbar puncture — clear cerebro- 
spinal fluid under increased intracranial pressure (approximately 16 mm.) ; 
Wassermann test negative. X-ray (Doctor A. J. Quimby) — "indistinct 
bony defect of 2 cm. in diameter in posterior portion of left frontal bone ; 
surrounding bony edge also depressed." 

Treatment. — The definite signs of an increased intracranial pressure and 
the presence of the bony defect and depression of the surrounding bone, 
together with the increased reflexes upon the right side — and especially 
after a competent and thorough medical treatment had failed to cause 
an improvement of the convulsive seizures, these facts made a left sub- 
temporal decompression advisable in the hope that the condition might 
be benefited ; naturally, if a decompression operation at this late date could 
improve the condition of the patient, how much more benefit would an earlier 
operation have obtained — possibly the convulsive seizures might even have 
been prevented from occurring at all. 

Operations (7 years after injury).— First, left subtemporal decompres- 
sion: usual vertical incision, bone removed, and no complications. Dura 
was thickened and under moderate tension ; upon incising it, much cerebro- 
spinal fluid escaped, revealing a very "wet, " edematous cortex; arachnoid 
was of cloudy appearance and about the vessels in the sulci was a whitish 
induration — the residue of a former subarachnoid hemorrage. Occasional 
adhesions found between the arachnoid and the overlying dura. Brain 
pulsated at end of operation. Usual closure with 2 drains of rubber tissue 
inserted. Temporary sterile dressing applied. 

Second Operation. — Curvilinear incision of 2 inches over depressed area 
of left frontal bone ; small trephine opening made at posterior edge of bony 
depression and the depressed area of spongy bone removed — new bone forma- 
tion apparently. Dura was thickened and vascular, requiring the applica- 
tion of three silver clips ; upon incising it, there was revealed an underlying 
cystic formation, bluish in color, and at least one-half inch in thickness ; this 
cyst was punctured, allowing a straw-colored fluid to escape. Dura closed 
with silk. Usual closure of scalp with one drain of rubber tissue inserted. 
Duration, 65 minutes. 

Post-operative Notes. — Uneventful operative recovery; at discharge, 
patient no longer complained of headache and did not appear so irritable. 
No convulsions have occurred since the operation; incision healed per pri- 



CHRONIC BRAIN INJURIES 



45i 



mam. A second X-ray picture shows ' ' the two bony defects of the left vault ; 
also three silver clips within a decompression area" (Fig. 136). 

Examination (June 12, 1914 — 70 days after operation). — No complaints 
in that the headaches have ceased and no convulsions have occurred ; from 
reports of his teachers in school, he is " a changed boy — not so unruly and 
has better control of his temper; is more attentive to his studies." Decom- 
pression area slightly depressed and pulsates normally. Reflexes — patellar 
active but equal ; no ankle clonus nor Babinski ; abdominal reflexes present 
and equal. Fundi — retinal veins only slightly enlarged ; no blurring edema 
of the nasal halves of the optic disks but the mild signs of a secondary 
optic atrophy naturally persist. 

Examination (April 6, 1916 — 24 months after operation). — Since the 
operation, patient has had 9 
convulsions* — the first one 
being 9 months after the 
operation; patient does not 
complain of headaches and 
he has made a marked im- 
provement in his school 
work ; he is emotionally more 
stable and no longer "loses 
his temper. ' ? Decompression 
area slightly depressed. Re- 
flexes active but otherwise 
negative. Fundi — retinal 
veins slightly enlarged; no 
edematous blurring of either 
optic disk; the mild sec- 
ondary optic atrophy is 
present. 

Last Report (July 10, 
1918—52 months after 
operation) . — Mother writes 

that "Joseph has had 11 convulsions during the past year but they do not 
upset him as they did before the operation ; he no longer has headache and 
seems bright in every way. ' ' 

Remarks. — Although this patient has undoubtedly been benefited by 
the operation in relieving the increased intracranial pressure and thereby 
lessening the cortical irritation, so that the convulsive seizures have been 
of less frequency and severity, yet the ultimate result, I feel, will be merely 
that the condition has been delayed and that the usual mental deterioration 
and emotional instability will result finally, as in practically all o\' these 
patients having convulsive seizures; the operation, however, was surely 
justified and if this patient had received the appropriate treatment imme- 
diately following the injury, it might have been possible to have prevented 
these convulsive seizures from occurring at all — at least, the patient would 
have had a greater chance of approximating a normal individual. The 




Fig. 136. — Oval bony defect of left subtemporal decom- 
pression in a patient having (seven years ago) a depressed 
fracture of the left vault followed by convulsive seizures. 
Marked improvement following the operative lowering of 
the increased intracranial pressure. 



452 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

operative findings of a former subarachnoid hemorrhage and a definite 
hemorrhagic cystic formation immediately beneath the bony depression of 
the vault and lying directly upon the cortex — these findings in themselves 
are undoubtedly of sufficient cortical irritation to produce the convulsive 
seizures, even in the absence of an increased intracranial pressure and espe- 
cially after the cortex itself has become irritable as the result of numerous 
preceding convulsions appearing over a period of several months and even 
years. It will be interesting to follow this patient during the next 5 and 10 
years. The following note was made within 2 months after his operation : 
' ' Considering the cortex as ascertained at operation, it seems incredible that 
the boy can remain improved permanently ; yet in adolescents, it appears that 
the cortex can return to a stable and less irritable condition of abnormality 
more easily than in adults, even though the traumatic epilepsy has persisted 
over a number of years. ' ' 

Case 110. — Old severe brain injury associated with a depressed fracture 
of the right frontal bone and with signs of an increased intracranial pres- 
sure; spells if petit mat and severe headache. Two operations: right sub- 
temporal decompression and then a removal of the depressed area of the 
vault. Recovery. 

No. 130. — Arthur. Thirty-seven years. White. Married. Coal-miner. 
United States. 

Admitted April 13, 1911 — 1 years after injury. Polyclinic Hospital. 
Referred by Doctor John I. Van Wert, Patton, Pa. 

Operations (April 21, 1911 — 1 years after injury) . — Right subtemporal 
decompression and removal of depressed area of vault. 

Discharged May 3, 1911 — 12 days after operations. 

Family history negative. 

Personal History. — Always well and strong. Four years ago, patient was 
struck over the right forehead by a wooden plank in a mine explosion; 
loss of consciousness for several minutes ; laceration of scalp over the right 
forehead but no depression of the underlying bone ascertained; patient 
remained at home and in bed for 17 days, having severe headache and dizzi- 
ness. Four months later, patient attempted to work but was unable to 
work longer than one day on account of the severe right frontal headache 
and dizziness ; during the past 3 years he has been able to work 1 or 2 days 
at a time and then he had to remain at home for a period of one week to one 
month on account of the severe headache, dizziness and, during the past 
6 months, momentary losses of consciousness while eating, talking and when 
he worked. Three years ago, the right frontal sinus was exposed and 
curetted but no real improvement resulted. Beside the headache, dizziness 
and the spells of petit mal, patient had become mentally and emotionally 
depressed, slept poorly and complained of a blurring of vision. His con- 
dition had been diagnosed at several clinics as being one of traumatic neuras- 
thenia and as hysteria. 

Examination upon admission (4 years after injury). — Temperature, 
98.8° ; pulse, 62 ; respiration, 20 ; blood-pressure, 160. Fairly well-developed 
and nourished. A slight depression of the right frontal bone of 2 inches in 
width and 1 inch in length; marked local tenderness. Pupils equal and 



CHRONIC BRAIN INJURIES 



453 



react normally. Reflexes— patellar present and equal; no ankle clonus 
nor Babinski; abdominal reflexes— left possibly less active than right. 
Fundi— retinal veins dilated ; edematous blurring of nasal margins of both 
optic disks, which were rather pale due to new tissue formation and thus 
producing a mild secondary optic atrophy. Lumbar puncture — clear cere- 
brospinal fluid under increased pressure (approximately 16 mm.) ; Wasser- 
mann test negative and cell count was 4 cells per c.mm. X-ray (Doctor A. J. 
Quimby) — "in right frontal area, two inches above right supra-orbital 
ridge, is an irregular bony depression and defect of the right frontal bone 
just to the right of the midline; it is rather hazy and indistinct at this 
point ; no linear fracture 
shown" (Fig. 137). 

Treatment. — If it were not 
for the presence of the signs 
of increased intracranial pres- 
sure, it would be very easy 
to consider this patient as hav- 
ing merely a functional condi- 
tion with possibly a slight 
injury to the right frontal 
bone itself; the signs of an 
increased intracranial pres- 
sure, however, immediately 
cause this patient to be re- 
moved from that large group 
of patients properly classified 
as functional and to be placed 
among those patients having 
definite organic conditions 
intracranially as the result of 
the cranial injury. It was 
thought advisable to perform 
a subtemporal decompression 
to lessen the increased intra- 
cranial pressure and then to remove the depressed area of bone in the belief 
that it might be a source of cortical irritation. 

Operations (4 years after injury). — First, right subtemporal decompres- 
sion : usual vertical incision, bone removed, and no complications ; bone was 
unusually thick with several large sinuses in the diploe. Dura was thickened 
and under marked tension; upon incising it, much cerebrospinal fluid 
escaped, revealing a very "wet," edematous cortex; the arachnoid was 
"smoky" and about the vessels in the sulci was much connective-tissue for- 
mation — the residue of a former subarachnoid hemorrhage ; there were many 
adhesions between the arachnoid and the overlying dura. The cortex bulged 
so that much cerebrospinal fluid eseaped and the arachnoid "sweated" so 
profusely that the cortex receded and pulsated normally at the end of the 
operation. Usual closure with 2 drains of rubber tissue inserted Tem- 
porary gauze dressing applied. 




Fig. 137. — Old depressed fracture of the right frontal bene 
followed by severe continuous headache and epileptiform spells, 
and associated with an increased intracranial pressure. At 
operation, a piece of wood (4x2 cm.) was found in the depressed 
area of bone. 



454 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Second Operation. — Removal of depressed area of right frontal bone and 
extraction of the foreign body ; curvilinear incision of 2 inches made over the 
depressed area ; healed line of fracture with callus formation was revealed, 
extending from the area of depression to the left over and beyond the longi- 
tudinal sinus, where it bifurcated ; protruding from this old line of fracture 
in the depressed area was a piece of wood 1% inches long and a quarter 
of an inch in diameter. The depressed area of bone and the foreign body ron- 
geured away; the underlying dura had apparently not been damaged and 
therefore it was not opened. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 70 minutes. 

Post-operative Notes. -Uneventful operative recovery; both scalp inci- 
sions healed per primam and at discharge patient no longer complained of 
severe headache or of dizzy spells. 

Examination (September 20, 1915 — 17 months after operation). — Patient 
states that he is better than at any time following the injury ; in fact, he no 
longer has headaches or dizzy spells, not a single attack of petit mal has 
occurred and in every way he seems to be, as he says, ' ' a new man. ' ' Patient 
went to work one month after the operation and has not missed a day since. 
Decompression area is flush with the surrounding scalp ; pulsates normally. 
Reflexes active but otherwise negative. Fundi — retinal veins slightly en- 
larged; no blurring of optic disk margins but the mild secondary optic 
atrophy naturally persists. 

Last Report (October 22, 1917 — 42 months after operation). — A letter 
has just been received from Doctor Van Wert stating that "the patient was 
killed one week ago in a mine explosion. The patient had enjoyed excellent 
health since the operation, had worked daily and there had been no com- 
plaints. ' ' The tragic ending of this patient is most unfortunate. 

Remarks. — It is undoubtedly a rather common mistake in diagnosis to 
consider post-traumatic conditions in patients as being practically all 
functional, and therefore frequently no careful neurological examination 
is made — especially the ophthalmoscopic examination of the fundi and the 
accurate estimation of the intracranial pressure by means of the spinal 
mercurial manometer at lumbar puncture; if such patients have an in- 
creased intracranial pressure, then they can no longer be considered as 
purely functional, and their post-traumatic symptoms of headache, vertigo, 
loss of sleep, emotional instability and the other numerous so-called neuras- 
thenic symptoms and signs, when associated with an increased intracranial 
pressure, have thus a definite organic basis for their impairment and should 
be treated accordingly ; post-traumatic neurasthenia and hysteria have been 
too frequently applied to post-traumatic conditions merely because, in many 
patients, careful examinations were not made. 

It was rather surprising in this patient to find the piece of wood imbedded 
in the bone ; it in itself, however, was not the cause of the patient 's condition 
but rather the ' ' wet, ' ' edematous condition of the brain resulting from the 
former subarachnoid hemorrhage and its resulting cerebral edema. 

Case 111. — Old severe brain injury associated with a depressed fracture 
of left parietal area of vault and with signs of increased intracranial pres- 
sure ; paraphasia and convulsive seizures. Two operations : left subtemporal 



CHRONIC BRAIN INJURIES 455 

decompression and then a removal of the depressed silver plate covering the 
bony defect. Excellent recovery. 

No. 180. — John. 37 years. White. Married. Hostier. United States. 

Admitted March 15, 1915 — 10 months after injury. Polyclinic Hos- 
pital. Referred by Doctor J. R. Bingham. 

Operations (March 27, 1915 — 10 months after injury). — Left subtem- 
poral decompression and removal of depressed area of vault. 

Discharged April 12, 1915 — 16 days after operations. 

Family history negative. 

Personal History. — Patient has always been well and strong ; never any 
severe illness; his life has been rather a hard, rough one and associated 
with much drinking. Ten months ago (June, 1914), patient was kicked 
upon the left side of head by a mule ; loss of consciousness for 30 minutes ; the 
scalp laceration was sutured and, upon recovering consciousness, the patient 
was unable to speak ; this condition of aphasia lasted for 5 weeks and has 
never entirely disappeared. Six weeks after the injury, patient had his 
first general convulsion and these continued at intervals of 2 weeks. Six 
months ago (October, 1914), a left osteoplastic bone flap operation was 
performed at a hospital: in Baltimore — the bone flap being removed at the 
end of the operation and a large silver plate placed over the bony defect. 
A definite improvement of the aphasia followed but the convulsive seizures 
returned after a period of 8 days with even greater severity than before 
the operation; since then, the "fits" have occurred every 6 to 10 days. 
Six weeks ago while aboard ship at a port in France, patient became intoxi- 
cated and during a fight was struck over the head by a heavy bottle ; imme- 
diate loss of consciousness for 2 hours and since that time, the convulsive 
seizures have become of still greater severity and frequency — one every 4 
days and lasting 2 to 3 hours each time. 

Present Illness. — Six hours ago, while standing upon the street corner, 
the patient had a severe convulsion, general in character and lasting 2 hours ; 
unable to talk during the following 3 hours; brought to the hospital in 
the ambulance. 

Examination upon admission (10 months after the original cranial 
injury). — Temperature, 99° ; pulse, 76; respiration, 18; blood-pressure, 142. 
Drowsy and confused mentally ; complains of severe headache. Well-devel- 
oped and nourished. Over the left parietal area of the vault was the curvi- 
linear scar of the former operative incision arching over the earlier scalp 
wound ; the silver bone plate was depressed to a depth of almost 1 cm. Hear- 
ing negative. Definite paraphasia; the speech was also very thick. 
Pupils equal and react normally. Reflexes: patellar, active but equal; 
no ankle clonus but suggestive right Babinski ; abdominal reflexes, 
both depressed — right possibly more than left. Fundi : retinal veins full ; 
nasal margins of both optic disks blurred by edema, Lumbar puncture : clear 
cerebrospinal fluid under increased pressure (approximately 15 mm.) ; Was- 
sermann test, negative and cell count was 7 cells per c.mm. X-ray (Doctor 
A. J. Quimby) — ' 'silver plate of former operation had become depressed to 
a depth of almost Vl> inch; no linear fracture ascertained" (Pig. 138). 
Treatment. — Patient was carefully examined during a period of 10 days; 



456 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

at the end of that time as the signs of an increased intracranial pressure 
persisted and the patient had had 3 convulsions of a general character 
although the right arm each time was involved before the left side of the 
body, it was considered advisable to perform a left subtemporal decompres- 
sion first and then to remove the depressed silver plate. 

Operations (10 months after injury).— First, left subtemporal decom- 
pression : usual vertical incision, bone removed and no complications ; rather 
anterior incision in order to expose the motor speech area (the patient and 
his relatives all being right handed) ; at the upper angle of the bony open- 
ing, there was a narrow bridge of bone, % inch in width, between the decom- 
pression opening and the line of fracture of the former osteoplastic 
operation. Dura was thickened, whitish and under tension ; upon incising 
it, clear cerebrospinal fluid oozed out, revealing a very "wet" edematous 

cortex ; about the vessel walls 
in the sulci and in the arach- 
noid itself was a whitish 
induration — the residue of 
a former subarachnoid hem- 
orrhage. A large supracor- 
tical vein was accidentally 
punctured, but its bleeding 
was quickly controlled by 
the application of a small 
piece of temporal muscle 
( which hastens the formation 
of a clot and thus facilitates 
the hemostasis). Owing to 
the escape of much cerebro- 
spinal fluid, the cortex now 
became relaxed and pulsated 
^ , oc t ii i + . ♦ k if* normallv. Usual closure 

tig. ldcS. — Large oval silver plate used to cover a bony defect *■ 

of the left parietal area. The silver plate became depressed, with 2 drains of rubber tlSSUe 

causing persisting symptoms and signs; its removal and a left sub- . 

temporal decompression permitted an excellent recovery. inserted. Temporary gauze 

. dressing applied. 

Second Operation. — Curvilinear incision of 2 inches over the center of the 
depressed silver plate ; small trephine opening made, enlarged by rongeurs to 
a diameter of 2 inches, and thus it was possible to remove the depressed silver 
plate. The underlying dura was thickened but not under tension, and there- 
fore it was not opened. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 80 minutes. Post-operative notes : Except for extreme restless- 
ness, the patient made an uneventful operative recovery; no convulsions 
occurred during his convalescence and as the headache had disappeared, the 
patient insisted upon his discharge on the eleventh day. 

Exariiination (February 20, 1917 — 25 months after operations) . — Patient 
has had only 4 convulsions since the operation — the last being 11 months ago ; 
he has been at work daily on an ice-wagon and insists that he is no longer 
drinking — a very important factor in this case. The decompression area is 
flush with the surrounding scalp, while the scalp is rather sunken at the 




CHRONIC BRAIN INJURIES 457 

site of the craniectomy and removal of the silver plate. There is a definite 
improvement of speech and the patient's entire general condition has been 
benefited. Reflexes active but otherwise negative. Fundi : retinal veins 
slightly enlarged ; optic disks clear but nasal margins are rather irregular 
from new tissue formation. 

Last Examination (August 28, 1918 — 41 months after operation). — 
Patient was met upon the street delivering ice ; " feeling fine. ' ' No convul- 
sions since the last examination — that is, during the last 29 months; has 
an occasional headache but only "light ones"; no longer drinks, and his 
son of 12 years of age, who was with him, corroborates this statement. De- 
compression area slightly depressed and pulsates normally. Reflexes active 
but otherwise negative. Fundi : retinal veins of normal size ; optic disks 
clear while the new tissue formation is still present along their nasal margins. 

Remarks,. — I believe that alcohol was a definite factor in this man's 
condition; that is, in addition to the cortical irritation due to the former 
subarachnoid hemorrhage and the depressed silver plate, that the drinking 
daily of a large amount of alcohol increased the resulting cortical irrita- 
bility, and thus not only predisposed the patient to convulsive seizures but 
also made the patient more susceptible to the so-called "epileptic habit." 
The lessening of the increased intracranial pressure by the decompression 
operation and the removal of the depressed silver plate — and at the same 
time, the cessation of the drinking of alcohol, made it possible for this patient 
to make an excellent recovery and that both were necessary in order to obtain 
this good result. 

In the presence of an increased intracranial pressure due to a former 
cranial injury in these patients, the mere osteoplastic operation with an open- 
ing of the dura, and then the dura resutured and the bone flap replaced — 
this operative procedure is not of permanent value in that the increased 
intracranial pressure is only lessened temporarily, and in these patients 
having a chronic edematous condition of the brain, it is essential that the 
decompression and drainage should be a permanent one — as is afforded by 
the subtemporal decompression; therefore, the subtemporal decompression 
is the more advisable, but if an osteoplastic flap operation is performed, then 
it should be associated with a subtemporal decompression to be performed 
at the same time. 

To remove a large portion of the vault of the skull and then to insert 
a so-called "protecting plate" of silver or other foreign body is distinctly 
a dangerous procedure and frequently associated with later complications — 
as in this patient. If a large bony defect is present and of a diameter of 
more than four inches, then it is better judgment for the patient to wear a 
tight-fitting skull cap with a metal plate in the cap and covering the bony 
defect rather than the surgeon attempting to insert beneath the sealp a 
foreign body of metal and trust that no complications will occur — both 
the immediate danger of infection and the later dangers of resulting cortical 
irritation. The inserted foreign body need not be depressed as in this 
patient in order to produce intracranial complication. 

Case 112. — Old severe brain injury associated with a depressed fracture 
of the left frontal bone and with signs of increased intracranial pressure: 



458 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

convulsive seizures. Two operations : left subtemporal decompression and 
then a removal of depressed area of bone. Improvement. 

No. 877. — Daniel. Thirty-six years. White. Single. Steward. Ireland. 

Admitted June 23, 1917 — 34 years after injury, Polyclinic Hospital. 
Referred by Doctor George W. Jacoby. 

Operations June 31, 1917. Left subtemporal decompression and removal 
of depressed area of bone. 

Discharged July 17, 1917 — 17 days after operation. 

Family history negative. 

Personal History. — Third child, full-term baby, normal delivery; con- 
sidered a normal child until cranial injury. When 2 years of age (34 
years ago) , the patient fell a distance of 10 feet, striking left forehead against 
a curbstone and causing a depression of the left frontal bone; 2 days 
later, he was operated upon and "a piece of the depressed bone removed, 
turned around and then placed back ' ' ; patient apparently made an excellent 
recovery and was considered a normal child until 9 years ago, at 27 years 
of age, when he was first troubled by nausea and dizziness, and finally 
a general convulsive seizure occurred ; within 6 months, these convulsive 
seizures increased in severity and frequency until they were occurring as 
often as once in every 10 days to 2 weeks. Eight years ago (February, 
1909), patient was operated upon at the German Hospital: "the skull was 
opened in the frontal region, the bone-flap turned down and the dura 
exposed; the dura showed an old scar and upon incision pronounced adhe- 
sions between it and the brain. A puncture into the frontal lobe resulted 
negatively. The adherent dura was excised, a silver leaf placed over the 
cortex and the bone put back. After the operation (and until June, 1912), 
this patient was carefully watched, but the operation had no effect whatso- 
ever upon his convulsions. ' ' During the past 5 years, the condition of the 
patient has remained practically the same — general convulsive seizures 
occurring one or more times weekly, and during the past 6 months, he 
has had one convulsion at least each day ; there has been a marked mental 
and emotional deterioration during this period — there being a marked im- 
pairment of memory ; continuous severe headaches daily, especially during 
the past 6 weeks. 

Examination upon admission (34 years after injury). — Temperature, 
98.6° ; pulse, 70 ; respiration, 20 ; blood-pressure, 136. Fairly well-nourished 
and developed. Curvilinear scar over left frontal bone — incision of former 
operation ; depressed area — apparently of bone and of one inch in diameter ; 
hard upon palpation and no pulsation obtained. No paralyses or impair- 
ment of sensation. Pupils equal and react normally. Reflexes: patellar — 
both active, right possibly more than left ; no ankle clonus but a suggestive 
right Babinski; abdominal reflexes — right less active than left. Fundi — 
retinal veins full; nasal margins and lower nasal quadrants of both optic 
disks blurred by edema ; small amount of new tissue formation along the 
margins of optic disks and in both physiological cups. Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (17 mm.) ; Wassermann 
test negative and cell count was 8 cells per c.mm. X-ray (Doctor G. W. 



CHRONIC BRAIN INJURIES 



459 



"VVelton) "depressed area of new bone formation in left frontal area; 

no linear fracture shown. ' ' 

Treatment. — Although the prognosis for this patient was practically 
hopeless, with or without operation — the convulsions having persisted over 
such a long period of time and following an injury of over 30 years ago, yet 
as there were present the signs of an increased intracranial pressure as 
revealed by the ophthalmoscope and as registered by the spinal mercurial 
manometer, it was considered advisable to perform a left subtemporal decom- 
pression and a removal of the new bone formation at the site of the depres- 
sion in the hope that the cortical irritation might thus be lessened and the 
convulsive seizures and their resulting mental and emotional deterioration 
be at least retarded and 
delayed. 

Operations (34 years y /A ' A 

after original brain injury). 
— First, left subtemporal de- 
compression: usual vertical 
incision, bone removed, and 
no complications. Dura very 
thick, vascular and tense, 
and upon incising it, much 
clear cerebrospinal fluid es- 
caped, revealing a very 
< ' wet, " edematous cor- 
tex, which protruded under 
moderate tension but did not 
rupture. Whitish indura- 
tion about the vessels in the 
sulci and of the overlying 
arachnoid — the possible resi- 
due of the former subarach- 
noid hemorrhage. Usual 
closure with 2 drains of rubber tissue inserted. Temporary sterile gauze 
dressing applied. 

Second Operation. — Curvilinear incision made through scar of former 
operation ; after much difficulty, the silver plate imbedded in much new bone 
formation was removed and the numerous adhesions to underlying dura 
which had apparently re-formed were separated. Upon incising the dura, 
there was exposed, lying* within the cortex itself, a bluish cystic mass — the 
size of a lemon; the outer wall of the cyst was excised, allowing straw- 
colored fluid to escape and then the cyst itself collapsed ; several adhesions 
between the C3 r st-wall and overlying dura were severed. The dural opening 
and the wound were closed in the usual manner with 2 drains of rubber 
tissue inserted beneath the scalp. Duration, 80 minutes. 

Post-operative Notes. — Uneventful operative recovery; patient, however. 
had one convulsion during his hospital convalescence ; patient seemed less 
confused mentally and felt that his headaches were less in severity upon 
discharge — 17 days after operation ; incision healed per primam. 




Fig. 139. — The large oval defect of the left frontal bone, 
following a removal of an old depressed fracture and a left 
subtemporal decompression in a patient having a high intra- 
cranial pressure with convulsive seizures. Marked improve- 
ment following the operation. 



4 6o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






Examination (November 20, 1917 — 5 months after operations). — After 
leaving the hospital, patient had his first general convulsion 7 weeks later, 
to be followed by the second one after a period of 8 weeks; he has had 
in all now since the operation 5 convulsions and is feeling better than ' ' for 
years"; he has a "light" position as a watchman — the first time he has 
been able to earn any money for 9 years. He no longer has headaches, and 
although his mentality is definitely retarded, he can now remember simple 
things, and he has sufficient emotional control so that he can live with his 
relatives and his relatives can live with him. Decompression area is flush 
with the surrounding scalp and pulsates normally. Reflexes — patellar active, 
right possibly more than left; no ankle clonus and plantar flexion cannot 
be elicited upon right foot ; abdominal reflexes — right slightly depressed. 
Fundi — retinal veins slightly enlarged; details of both optic disks clear, 
though new tissue formation naturally is present. X-ray (Doctor W. H. 




Figs. 140 and 141. — Eighteen months following the operation of removal of depressed fracture 
of left frontal bone and a left subtemporal decompression with marked improvement of the symptoms 
and signs. 

Stewart) — "bony defect of left frontal area and the oval decompression 
defect with three silver clips in situ are clearly demonstrated ; no linear 
fracture shown" (Fig. 139). 

Last Examination (December 2, 1918 — 18 months after operation). — 
During the past year, patient has had a general convulsive seizure about 
every 6 to 8 weeks ; in the intervals, however, he is able to hold his position 
as a watchman and enjoys life in a simple way. The convulsions are not 
causing a marked mental and emotional deterioration, as they were before 
the decompression was performed ; he no longer has headaches. Decompres- 
sion area slightly depressed beneath flush of scalp ; pulsation normal. Re- 
flexes — patellar active, right possibly more than left; no ankle clonus nor 
Babinski ; abdominal reflexes — right less than left. Fundi — retinal veins 
slightly enlarged ; all details of both optic disks clear and distinct ; new 
tissue formation along optic disk margins and in both physiological cups 



CHRONIC BRAIN INJURIES 461 

is still present. Photographs (Figs. 140 and 141) disclose the amount of 
deformity and disfiguration. 

Remarks. — Since the operations in June, 1917, I have examined this 
patient almost weekly at the hospital clinic and it has been most interest- 
ing to observe his mental and emotional improvement; he is now anxious 
to do some other form of work than that of watchman and his emotional 
stability has been so benefited that his relatives state he is a " changed man. ' ' 
This patient was operated upon almost as a forlorn hope — merely to give 
him a possible chance of improvement, and I believe the results obtained up 
to the present time certainly justify the attempt to improve his condition ; 
from the pathology revealed at the operation, it would be too much to expect 
an ultimate recovery, but the improvement effected is most encouraging — 
no matter what the end-result may be. 

The above photographs illustrate the small amount of disfiguration of the 
bony defect in the left frontal area ; surely, no silver plate or other foreign 
body should be inserted for protection. 

Although it is most gratifying that the convulsive seizures have lessened 
both in severity and frequency in this patient (and therefore the operations 
are justified even though this improvement of the patient's condition is only 
temporary), it is difficult to conceive that this patient can be so benefited 
that the convulsions will cease ; it would seem that in patients having brain 
injuries for a long period of years and then finally convulsive seizures do 
occur, and if these convulsions are permitted to continue for any length of 
time so that they become at all frequent — more than one a week, that the end- 
result, operation or no operation, is very doubtful; the lessening of the 
increased intracranial pressure, however, will in many of these patients 
delay and retard the rapid progress of the mental and emotional deteriora- 
tion and from this standpoint alone the operation of subtemporal decom- 
pression in selected patients is more than justified. 

D. Chronic Brain Injuries Associated with a Fracture of the Base 
of the Skull and with the Symptoms and Signs Persisting; Minor 
and Major Epilepsy. Subtemporal Decompression. 

From what has been stated before, the patients in this series who were 
operated upon were only selected ones in whom the mental and emotional 
deterioration had not been severe, the epileptic "habit" not of long duration 
or severity, and in whom there were marked signs of an increased intra- 
cranial pressure which had been ascertained as being primary and not sec- 
ondary to the convulsions themselves — that is, the increased intracranial 
pressure was not the result of the convulsions but a possible factor in their 
causation. These are the patients and the only ones — whether there has 
been a fracture of the base of the skull or not — for whom the operation of 
subtemporal decompression can be advised as offering a percentage of these 
patients a definite chance of relief; naturally, the longer the condition has 
persisted since the original brain injury, and especially in those conditions 
complicated by epilepsy in its major form, the less hopeful is the prognosis 
following any operative procedure. 

D. Chronic brain injuries associated with a fracture of the base of the 



462 DIAGNOSIS AXD TREATMENT OF BRAIN INJURIES 

skull; symptoms and signs persisting; minor and major epilepsy. Sub- 
temporal decompression. 

a. Marked improvement. 

Case 113. — Old severe brain injury associated with a fracture of the 
skull and with signs of an increased intracranial pressure : convulsive seiz- 
ures. Right subtemporal decompression. Excellent recovery. 

No. 070. — Henry. Twenty years. Colored. Single. Sailor. U. S. 

Admitted October 10. 1913 — 1 year after injury. Polyclinic Hospital. 
Referred by Doctor J. E. Engelson. 

Operation October 21. 1913. Right subtemporal decompression and 
drainage. 

Discharged October 27. 1913 — 7 days after operation. 

Family history negative. 

Personal History. — Always well and strong: is not alcoholic. One year 
ago. patient fell a distance of 20 feet from the main mast down upon the 
deck, striking upon the top of his head : immediate loss of consciousness and 
profuse bleeding, with a " watery" discharge, from both ears: upon arrival 
in port 2 days later, patient was taken to the Marine Hospital. Brooklyn, 
where he remained unconscious for 8 days ; he was discharged on the 
twelfth day in a stuporous condition and became unconscious upon reaching 
home. Patient was able to leave the house 2 weeks later, but complained 
of severe headache: vomited almost daily and 2 months later [9 months 
ago j . patient had his first general convulsive seizure. Beside the severe head- 
aches, dizziness and frequent attacks of vomiting, patient has fainted 
2 to 4 times each day during the past 6 months and has had a general convul- 
sive seizure at least once a week ; definite blurring of vision. 

Examination upon admission \1 year after injury . — Temperature. 
98.8 : : pulse. 6S : respiration. 16: blood-pressure. 148. "Well-developed and 
nourished negro. Complains of severe headache ; while sitting upon the 
bench in the hospital clinic, patient had a convulsive seizure (no localizing 
signs) and vomited profusely and forcefully — almost projectile in character; 
pulse descended to 62 during the attack and respirations to 12. Head nega- 
tive. Hearing negative : otoscopic examination revealed an irregular scar 
over the lower posterior portion of the right tympanic membrane : left tym- 
panic membrane negative : air conduction greater than bone conduction in 
both ears. Pupils equal and react normally. Reflexes — patellar increased but 
equal: no ankle clonus but tendency to a left Babinski: abdominal reflexes 
not active but equal. Fundi — retinal veins dilated ; nasal margins of both 
optic disks slightly blurred: both optic disks rather pale from new tissue 
formation in both physiological cups and along the margins — that is. a mild 
secondary optic atrophy. Lumbar puncture — clear cerebrospinal fluid 
under increased pressure (approximately 16 mm. : "Wassermann test nega- 
tive and cell count was 5 cells per c.mm. X-ray Doctor A. J. Quimby) — 
''no fracture visible.*' 

Treatment. — The definite history of convulsive seizures in a patient hav- 
ing a definite history of fracture of the base of the skull to be followed 
by spells of petit mal and finally by convulsive seizures in a patient having 
definite signs of an increased intracranial pressure and in the absence of 



CHRONIC BRAIN INJURIES 463 

luetic infection — these facts made it advisable to perform a right subtem- 
poral decompression even at this late date in the hope that a lessening of the 
increased intracranial pressure would diminish the cortical irritation and 
thereby cause an improvement. 

Operation (1 year after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed, and no complications ; removal of 
bone was rather difficult technically on account of its being rather ' ' ivory ' ' 
and thick. Dura thickened, fairly vascular and very tense ; upon incising 
it, much cerebrospinal fluid escaped, revealing an edematous cortex which 
bulged into the dural opening but did not rupture ; much arachnoid ' ' sweat- 
ing. " Numerous adhesions between arachnoid and dura and these were 
severed as far as possible beyond the dural opening. Except for the ' ' wet ' 7 
condition of the brain (chronic cerebral edema), the cortex was normal. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery; patient had no 
spells during hospital residence — headaches disappeared and upon patient 's 
insistence, he was discharged 7 days after operation ; incision healing 
per primam. 

Examination (May 16, 1914 — 7 months after operation). — Patient has 
not had an attack of petit mal or a general convulsive seizure since the 
operation ; no headache, and says he feels perfectly well. He began work on 
board ship 2 weeks after leaving the hospital and has been working ever since ; 
he promises to come for an examination whenever in this port. Reflexes — 
patellar very active but equal ; no ankle clonus nor Babinski ; abdominal 
reflexes present and equal. Fundi — retinal veins slightly enlarged but not 
abnormally ; details of both optic disks clear ; mild secondary optic atrophy 
is naturally still present. 

Examination (October 28, 1915 — 24 months after operation). — Only one 
general convulsion since the operation and that occurred following the 
drinking of gin in Havana 6 months ago ; he has had, however, 7 spells of 
petit mal — always following a heavy meal and after severe exertion; last 
attack was 3 weeks ago. No headache. Decompression area slightly de- 
pressed below flush of scalp. Reflexes active but otherwise negative. Fundi 
— retinal veins within normal limits of size -, no edematous blurring of optic 
disks, which are rather pale, due to the earlier new tissue formation. 

Last Examination (March 6, 1918 — 53 months after operation) . — Patient 
is now in the army transport service and has no complaints at present. 
although during the past 2 years he has had 6 spells of petit mal — not 
sufficient, however, to make him stop working; no general convulsive seiz- 
ure during the past 3 years; no headache. Decompression area depressed 
and pulsates normally. Reflexes active but otherwise negative. Fundi — 
retinal veins of normal size ; all details of both optic disks clear and distinct ; 
mild secondary optic atrophy naturally still present. 

Remarks. — It will be necessary to trace this patient over a longer period 
of time before it can be asserted that the patient is entirely well ; the good 
result obtained so far, however, is undoubtedly due to the comparatively 
early lessening of the increased intracranial pressure and especially in a 
person whose intellectual and emotional activities are of a lower order and 



464 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

possibly more elemental, so that this patient is not subjected to the strain 
and stress of modern life to which many white patients are subjected; 
besides, the nervous system of the negro race is not so delicately adjusted 
as that of the white race and is therefore possibly more stable in withstanding 
the effects of cortical irritation due to an increased intracranial pressure 
resulting from traumatic cerebral edema. The bad effect of alcohol upon 
these patients having an increased irritability of the cerebral cortex has often 
been observed and its use cannot be too strongly condemned. 

The cessation of headache following the operation of decompression in 
these patients is very impressive ; the dural tension, being lessened by the 
permanent opening and incision of the dura, is undoubtedly the usual cause 
of the headache. 

The complete recovery of hearing following the rupture of the tympanic 
membrane in these patients occurs in over fifty per cent, of the cases, so 
that air conduction is greater than bone conduction. 

Case 114. — Old severe brain injury associated with a fracture of the base 
of skull and with signs of an increased intracranial pressure; convulsive 
seizures and motor aphasia with mild hemiparesis. Left subtemporal decom- 
pression. Recovery. 

No. 050. — John. Thirty-eight years. White. Married. Laborer. L T . S. 

Admitted May 16, 1914 — 7 months after injury, Polyclinic Hospital. 
Referred by Doctor E. S. Bishop. 

Operation May 22, 1914. Left subtemporal decompression and drainage. 

Discharged June 4, 1914 — 12 days after operation. 

Family history negative. Patient and all of his relatives are right- 
handed. 

Personal History. — Always well and strong* ; not alcoholic. Seven months 
ago, while loading a boat, patient was struck upon the left side of the head 
by a bucket of coal; unconscious for several minutes and a blood-tinged 
' ' watery ' ' fluid trickled from the left ear ; was able to walk home but he could 
not speak for 3 days following the injury; after remaining home for 10 days, 
patient attempted to work, but on account of the severe continuous headache 
he was unable to work for more than 2 or 3 days each week. Two months 
ago, after a series of very severe headaches, he had the first general con- 
vulsion; 10 days later, the second general convulsion occurred — beginning 
in the right side of face, then right arm, right leg and finally the entire 
body, and it continued for 25 minutes. Since the injury, patient has had 
a definite impairment of speech — unable to use the proper word at times and 
even has difficulty in repeating words, although he could write them — the 
motor type of aphasia. There has been a distinct change of disposition 
in that the patient has become more irritable, while the memory has become 
definitely impaired, especially for recent events. During the past 3 weeks, 
convulsions have occurred as frequently as 7 times a day — always beginning 
on the right side of the face and then extending to the right arm and right 
leg and finally a general convulsive seizure occurred ; the patient is unable 
to speak a word for several hours after each attack — almost a pure type 
of motor aphasia; no agraphia or sensory involvement (word blindness, 
word deafness, etc.). 



CHRONIC BRAIN INJURIES 465 

Examination upon admission (7 months after injury). — Temperature, 
100° ; pulse, 80 ; respiration, 22 ; blood-pressure, 146. Well-developed and 
nourished. Unable to speak — merely nods head; considered "stupid" on 
account of the impairment of speech. Definite weakness of entire right side 
of body, especially of right side of face and right arm (right facial paresis 
is of the cortical type in that the right forehead muscles are not involved). 
Hearing of left ear less acute than that of right ; bone conduction equals that 
of air conduction; otoscopic examination reveals a small scar of a for- 
mer perforation in the upper posterior portion of the left tympanic mem- 
brane. Pupils equal and react normally. Reflexes — patellar exaggerated, 
right more than left ; slight right ankle clonus but no Babinski ; abdominal 
reflexes — right depressed. Fundi — retinal veins dilated ; nasal halves of 
both optic disks blurred by edema — left possibly more than right. Lumbar 
puncture — clear cerebrospinal fluid under increased pressure (approxi- 
mately 15 mm.) ; Wassermann test negative and cell count was 4 cells per 
c.mm. X-ray (Doctor A. J. Quimby) — "no fracture of the skull is shown." 

Treatment. — In the hope that a mechanical lessening of the increased 
intracranial pressure of this patient would result in an immediate improve- 
ment of the condition, so that the headaches would disappear, the convul- 
sions cease, the paraphasia improve and the weakness of the right side of the 
body become less marked, a left subtemporal decompression was advised. 

Operation (May 22, 1914 — 7 months after injury). — Left subtemporal 
decompression : usual vertical incision, bone removed, and no complications. 
Dura thickened and under high tension; upon incising it, a large amount 
of clear cerebrospinal fluid escaped, revealing an edematous cortex ; typical 
arachnoid "sweating"; the protruding cortex did not rupture and by the 
end of the operation, the pulsations were normal. Much induration of new 
tissue formation in the arachnoid and about the cortical veins in the sulci ; 
numerous adhesions between arachnoid and overlying dura and these were 
severed. Usual closure with 2 drains of rubber tissue inserted. Duration, 
40 minutes. 

Post -operative Notes. — Uneventful operative recovery; within 4 days 
after operation, patient was able to speak several sentences, using the words 
in continuity and correctly; convulsive seizure of a mild general type 
occurred on the seventh day post-operative ; no complaint of headache, 
however, and patient insisted upon being discharged on the twelfth day 
post-operative ; incision healed per primam. 

Examination (July 6, 1914 — 44 days after operation). — General im- 
provement continues ; no convulsions and no headache except for a ' * heavy 
dullf eeling " in the head; still paraphasic but much better; slight weakness 
of right arm, but he no longer limps upon the right leg and no facial weak- 
ness can be elicited. Decompression area flush with the surrounding scalp ; 
normal pulsation. Reflexes — patellar active, right greater than left ; no 
ankle clonus and no Babinski ; abdominal reflexes — right possibly less active 
than left. Fundi — retinal veins only slightly enlarged; nasal margins of 
both optic disks indistinctly blurred. 

Examination (October 21, 1916—29 months after operation V— Patient 
has had only 3 major convulsive seizures since the operation and 7 spells of 
30 



466 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

petit mal — momentarily losing consciousness, but of such short duration that 
patient did not fall. Speech has so improved that he can repeat with only 
an occasional error the following* test phrases: "Around the rugged rock, 
the ragged rascal ran"; "The third red riding artillery brigade"; "Con- 
stantinople"; "Truly rural"; "The sea ceaseth and it rejoiceth us." No 
agraphia. There is still a slight weakness of the right hand-grip and pos- 
sibly some awkwardness in performing the various pointing tests, butpatient 
is able to do his work almost as well as before the injury ; he tires more easily, 
however, and requires, he says, 10 hours sleep each night. Reflexes — patellar 
active, right possibly greater than left; no ankle clonus nor Babinski; 
abdominal reflexes present and equal. Fundi negative. Decompression 
area depressed and pulsates normally. 

Last Report (September 16, 1918 — 52 months after operation). — Patient 
has had only 2 convulsive seizures during the past 2 years and these, he 
writes, were only "light ones." He has no marked complaints and works 
daily. No trouble with speech, although he occasionally skips a word, but 
"no one notices it." No alcoholism. 

Remarks. — An unusually excellent result has up to the present time 
been obtained in this patient and it has undoubtedly been due to the fact 
that the cranial injury was a comparatively recent one and that the convul- 
sive seizures were of only 2 months ' duration ; they were occurring, however, 
so rapidly during the 3 weeks preceding the operation that the prognosis 
was very doubtful. This patient was in excellent physical condition and, 
together with the absence of alcoholism, made the good result possible. 

The definite right hemiparesis and motor aphasia with an occasional con- 
vulsion beginning in the right arm — these localizing signs were probably 
due to a cerebral edema as revealed at operation rather than to a supra- 
cortical or cortical hemorrhage, which was not disclosed; there could be 
found no extracranial cause for the development of the cerebral edema and 
naturally the subarachnoid hemorrhage occurring at the time of the injury 
must be considered an etiological factor in its production. 

A pure motor aphasia is a very rare condition; almost all of these 
so-called "aphasias" are really variations of paraphasia — there being 
usually a sensory element in their formation. I do not consider this patient 
to have had a true condition of motor aphasia. 

Case 115. — Old severe brain injury associated with a fracture of the base 
of the skull and with signs of an increasing intracranial pressure ; convulsive 
seizures. Right subtemporal decompression. Recovery. 

No. 173. — Julius. Fifty-two years. \Yliite. Married. Tailor. Russia. 

Admitted July 2, 1914 — 8 months after injury, Polyclinic Hospital. 
Referred by Doctor Alexander Lyle. 

Operation July 9, 1914. Right subtemporal decompression and drainage. 

Discharged July 26. 1914 — 17 days after operation. 

Family history negative. 

Personal History. — Always well and strong ; no alcoholism. Eight months 
ago, patient was knocked down by an automobile ; immediate loss of con- 
sciousness ; profuse bleeding from right ear ; taken in an ambulance to a 
hospital where he remained 2 weeks ; unconscious for 2 days. Since his dis- 



CHRONIC BRAIN INJURIES 467 

charge from the hospital, patient has had severe constant headaches and a 
haziness of vision, which has been increasing. Three months ago, patient 
had the first general convulsion — no localizing signs ; second general convul- 
sive seizure occurred 10 days later and during the past 3 months, patient has 
had 8 convulsions of major character. 

Examination upon admission (8 months after injury). — Temperature, 
98.2° ; pulse, 64 ; respiration, 30 ; blood-pressure, 164. Fairly well-developed 
and nourished. Complains of severe headache and is unable to tell a con- 
nected story. Rather "doughy" feel to entire posterior half of scalp with 
marked tenderness upon pressure. Hearing negative ; otoscopic examination 
reveals* a recent scar in the posterior lower quadrant of right tympanic mem- 
brane ; air conduction greater than bone conduction. No paralyses or im- 
pairment of sensation ; left-hand grasp possibly weaker than right. Pupils — 
moderately contracted, equal and react to light sluggishly. Reflexes — patel- 
lar very much exaggerated, left greater than right; no ankle clonus but 
left Babinski; abdominal reflexes — left less active than right (at this point 
of the examination, the patient suddenly had a convulsion beginning in the 
left arm, then left leg, and finally the entire body ; duration was 2 minutes) . 
Fundi — retinal veins dilated ; nasal margins of both optic disks blurred and 
both nasal halves rather indistinct. Lumbar puncture — clear cerebrospinal 
fluid under increased pressure (approximately 16 mm.) ; "Wassermann test 
negative and cell count was 7 cells per c.mm. X-ray (Doctor A. J. Quimby) 
— "no fracture visible." 

Treatment. — The history of cranial injury followed by convulsive seiz- 
ures and associated with signs of an increased intracranial pressure indi- 
cated the advisability of a lowering of the increased intracranial pressure 
by means of a right subtemporal decompression, in the hope that the cortical 
irritation could thus be lessened and the convulsive seizures be prevented ; to 
relieve the headache alone would be of great value to the patient. Naturally. 
if an operation is to be performed now, it would have been much better 
if the operation had occurred immediately following the injury and thus 
the great danger of convulsive seizures would have been very much les- 
sened ; that is, it is much better judgment to relieve the intracranial pressure 
early and thus prevent complications rather than to operate upon patients 
after the complications have occurred — and they do occur in almost 70 per 
cent, of these non-operated patients having brain injuries associated with the 
signs of increased intracranial pressure. 

Operation (8 months after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed, and no complications ; both the subcu- 
taneous tissue and the temporal muscle were still "boggy" and contained 
much old blood from the former cranial injury. Dura thickened and under 
high tension ; upon incising it, clear cerebrospinal fluid spurted to a height 
of 2 cm.; the underlying edematous cortex bulged but did not rupture, 
as the cerebrospinal fluid escaped in large quantities. Snpracortical vessels 
and arachnoid had a large amount of new tissue formation in and about 
them — the residue of a former subarachnoid hemorrhage. As the cortex 
receded and pulsated normally, it was not considered advisable to perform 
a bilateral decompression, as the pressure had been so greatly lessened by 



468 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

this operation. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery; several twitches 
of mild degree occurred in the left arm and left side of face during the opera- 
tive convalescence, but no general convulsive seizure occurred. Patient felt 
so well that it was with great difficulty that he could be kept in the hospital 
until the seventeenth day post-operative when he was discharged ; incision 
healed per primam. 

Examination (September 12, 1915 — 14 months after operation). — Patient 
has had 3 general convulsive seizures since the operation and all occurred 
during the month of February, 1915 — 7 months ago ; no exciting factor was 
ascertained as being the cause for these 3 convulsions, but he had complained 
of headache and dizziness during the preceding week. Patient has been able 
to work during the past 5 months ; no longer complains of headache and has 
improved both mentally and especially emotionally. No weakness of the arms 
or legs elicited. Reflexes — patellar active, left greater than right ; no ankle 
clonus but tendency to a left Babinski ; abdominal reflexes present and equal. 
Fundi — retinal veins rather full; only lower nasal margins of both optic 
disks slightly blurred — other details being distinct. Decompression area 
slightly depressed below flush of scalp and pulsates normally. 

Examination (October 20, 1917—39 months after operation). — During 
the past 2 years, patient has had 6 general convulsive seizures — 2 convulsions 
occurring on the same day 3 different times ; no precipitating cause for 
these attacks could be ascertained. Patient, however, has been able to work 
daily and has no complaints except the fear of another attack ; no headache 
nor dizziness. No weakness of the extremities either subjectively or objec- 
tively. Decompression area depressed and pulsates normally. Reflexes — 
patellar active but otherwise negative. Fundi negative, except for slight 
enlargement of retinal veins. 

Last Report (November 20, 1918 — 52 months after operation). — Son 
writes that patient has had only 2 convulsive seizures during the past year, 
but that he has had several "slight faints" — apparently a petit mal attack 
with no muscular contractions. Patient is working daily and has no real 
complaints except the spells. 

Remarks. — Whether this condition of occasional convulsive seizures will 
gradually subside or whether it will develop into the more serious con- 
dition of frequent convulsions cannot be stated Avith certainty; the latter, 
however, is to be feared, and especially is this true in patients over 
50 years of age in whom arteriosclerotic changes are becoming more and 
more pronounced. 

It would seem that the chronic cerebral edema following the cranial 
injury and subarachnoid hemorrhage had been sufficient by their irritation 
to precipitate convulsive seizures, and that the operation of right subtem- 
poral decompression had so lessened this increased intracranial pressure 
and thereby, to a large extent, the irritative presence of a supracortical 
residue of a former subarachnoid hemorrhage, that the progress of the 
condition had at least been delayed and retarded and it is hoped possibly 
cured; from the subsequent history of the patient following the operation, 



CHRONIC BRAIN INJURIES 469 

and especially during the past 2 years, it is doubtful that this latter good 
result will be obtained. 

The rapid recovery of normal hearing of the right ear is very impressive 
since only 8 months have elapsed since the cranial injury ; the fact that the 
air conduction was greater than the bone conduction within that short 
period of time indicates that the transmission mechanism of the right middle 
ear was not permanently damaged. 

Case 116. — Old severe brain injury associated with a fracture of the 
base of the skull and with signs of an increased intracranial pressure ; convul- 
sive seizures. Right subtemporal decompression. Improvement. 

No. 15. — Richard. Forty-five years. White. Married. Ice-man. Ireland. 

Admitted January 5, 1915 — 10 years after injury, Polyclinic Hospital. 
Referred by Doctor T. H. Morgan. 

Operation January 13, 1915. Right subtemporal decompression and 
drainage. 

Discharged February 5, 1915 — 23 days after operation. 

Family history negative. 

Personal History. — Always well and strong; only moderate use of 
alcohol. Ten years ago, while patient was racing upon a bicycle in Ireland, 
he fell, striking his head against a large stone ; immediate loss of conscious- 
ness which persisted for 3 days; blood and a "watery" fluid discharged 
from the right ear; the patient gradually recovered but severe headaches 
continued for several months and then subsided. Six years ago (4 years 
after injury), patient had the first convulsive seizure following an unusually 
severe headache over a period of one month j no localizing signs. The second 
spell occurred 6 weeks later, and the third spell one month after the second ; 
they increased both in frequency and in severity until 3 years ago (3 years 
after the first attack) , the patient was having at least one severe seizure every 
10 days to 2 weeks ; 3 years ago, an osteoplastic flap operation was performed 
at Bellevue Hospital over the left posterior parietal area; nothing grossly 
abnormal was noted and the bone-flap was replaced (much difficulty recorded 
in suturing dura on account of the protrusion of the underlying cortex and 
the dura could not be closely sutured). Within one month after this opera- 
tion, the convulsive seizures returned and apparently with greater severity in 
that the patient would remain unconscious for a period of 3 to 10 hours, to be 
followed by the most severe headache. Since this time and during the past 
3 years, the convulsive seizures have increased in frequency and severity so 
that he now remains unconscious for a period of 8 to 25 hours following an 
attack and he has been unable to work during the past year for more than a 
few. days at a time; headaches are extreme and the patient has deteriorated 
both mentally and emotionally, especially in the past 3 months. 

Examination upon admission (10 years after injury). — Temperature, 
99°; pulse, 70; respiration, 18; blood-pressure, 142. Large and unusually 
well-developed man, weighing 204 pounds. Patient is in a rather confused 
state mentally — this condition being exaggerated as the result of his having 
had a very severe convulsion 30 hours previously. Many small sears of 
former scalp lacerations are scattered over his head and also both sides of the 
tongue are badly lacerated. Over the posterior portion of the left parietal 



470 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

bone is a large horse-shoe incision — the site of the former operation. No 
paralyses nor impairments of sensation. Hearing negative; air conduction 
is greater than bone conduction. Pupils equal and react to light normally. 
Reflexes — patellar exaggerated but equal; no ankle clonus nor Babinski; 
abdominal reflexes rather depressed but equal. Fundi — retinal veins dilated ; 
nasal halves and temporal margins of both optic disks blurred by edema; 
physiological cups shallow from new tissue formation. Lumbar puncture — 
clear cerebrospinal fluid under increased intracranial pressure (approxi- 
mately 16 mm.) ; Wassermann test negative and cell count 8 cells per c.mm. 
X-ray (Doctor A. J. Quimby) — "site of former osteoplastic flap operation 
over posterior portion of left parietal bone ; no line of fracture revealed/' 

Treatment. — The history of a definite brain injury followed later by 
convulsive seizures and associated with the signs of a definite increase of 
the intracranial pressure made advisable the operative relief of this increased 
intracranial pressure, in the hope that the convulsive seizures could be 
lessened in frequency and severity and the rapid progress of the condition 
be at least delayed ; naturally, the prognosis was very grave and the opera- 
tion was performed merely in the belief that if the cortical irritation could 
be lowered, then a definite improvement would be possible. 

Operation (10 years after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed, and no complications ; an unusually 
difficult operation technically in that the bone was very thick, hard and 
brittle ("ivory"), and because the temporal muscle was very thick and 
resistant, making retraction very difficult. Dura whitish and thickened, with 
many adhesions to the overlying bone ; exceedingly tense and upon incising 
it, clear cerebrospinal fluid welled out, exposing an unusually "wet,' 7 ede- 
matous cortex which tended to protrude but did not rupture owing to the 
rapid escape of much cerebrospinal fluid; typical arachnoid "sweating." 
Along the vessels in the sulci and in the arachnoid itself was a large amount 
of new tissue formation giving these structures a hazy, cloudy appearance 
and due most probably to a former subarachnoid hemorrhage. Usual closure 
with 2 drains of rubber tissue inserted. Duration, 55 minutes. 

Post-operative Notes. — Uneventful operative recovery with the exception 
that upon the seventh day, a small amount of yellowish creamy pus appeared 
at the lower angle of the incision ; a small amount of this pus ( ' ' staphylo- 
cocci") continued to be discharged during the following 7 days when the 
wound finally healed. (There is no excuse for an infection of this character 
to occur in a " clean ' ' case ; the danger is very great indeed,; and it simply 
means that the operator or the other members of the team have been ' ' dirty, ' ' 
and less frequently so, infective operative material; fortunately in this 
patient, the infection did not result fatally.) No convulsions occurred dur- 
ing the hospital convalescence and the patient was discharged on the twenty- 
third day post-operative. Upon arriving home, patient had a slight general 
convulsive seizure, or rather twitching, lasting only 30 seconds ; no mental 
confusion nor emotional upset, however, followed. 

Examination (September 8, 1916 — 19 months after operation). — Patient 
has had only 5 general convulsive seizures since the operation and the 
severity of each attack has become very much lessened; he has never re- 



CHRONIC BRAIN INJURIES 471 

mained unconscious for longer than one hour and has been able to resume his 
work the same day of the attack ; only occasional dull throbbing headache — 
at which time the decompression area bulges ; the patient has been able to 
work during the past 9 months. The decompression area is slightly depressed 
and pulsates normally. Reflexes very active but otherwise negative. Fundi 
— retinal veins enlarged ; nasal margins of both optic disks slightly blurred, 
but the new tissue formation in both physiological cups and along the nasal 
margins of the optic disks is naturally still present; both disks possibly 
paler than normal — due probably to new tissue formation. 

Last Examination (August 28, 1918 — 43 months after operation). — 
Patient has now had 11 general convulsive seizures in all since the opera- 
tion; no attack, however, during the past 11 months and he feels "in the 
best of health and spirits." Patient has a heavy dull feeling in the head 
about every 10 days, but it is most unusual for him to have a headache of 
any severity — the last one being almost 6 months ago. He has made a 
marked improvement mentally in that he has become more alert and is 
able to conduct his- ice business much more successfully; no longer loses 
his temper unless the provocation is extreme. Decompression area is slightly 
depressed beneath the flush of scalp and pulsates normally. Reflexes active 
but otherwise negative. Fundi — retinal veins enlarged; nasal margins of 
both optic disks slightly blurred by edema ; new tissue formation naturally 
persists as at the preceding examination. 

Remarks. — The post-operative history of this patient is most instructive 
and encouraging. The osteoplastic flap operation could naturally be of no 
permanent benefit to the patient in the presence of the increased intracranial 
pressure, because, if there was no gross lesion removed at the operation, the 
dura would have been opened only temporarily and the bone-flap then 
replaced, and naturally under these conditions there could not have been 
formed a permanent decompression, so that within a few days after the 
operation the intracranial pressure would have attained its former degree 
of pressure and thus the condition would not have been relieved at all to 
any appreciable degree ; besides, the greater risk of this operative procedure, 
both from a technical standpoint and from the fact that it was performed 
"high up" over the more highly developed area of the cortex — the motor- 
sensory region. It is not surprising, therefore, that the convulsions quickly 
returned and this has been the history of the vast majority of patients 
having convulsive seizures — whether traumatic or otherwise, who have had 
cranial operations of the osteoplastic type performed upon them — and 
especially is this so in the presence of a definite increase of the intracranial 
pressure. Whether this patient will remain in this improved condition 
or will gradually return to the former condition of frequent and severe 
convulsive seizures — only the careful following of his case over a long period 
of years will tell ; if, however, the cortical irritation has been lessened suffi- 
ciently by the lowering of the increased intracranial pressure of the cerebral 
edema by means of the decompression, then the prognosis should be more 
hopeful and a good result is possible. One, however, cannot allow himself 
to become too optimistic regarding patients of this character, because they 
may appear improved for a period of months and even years, and then with- 



472 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

out any cause that can be ascertained, the patient will undergo a series of 
convulsive seizures that result most disastrously. 

This patient again illustrates the complete recovery of hearing of the 
right ear even after a discharge of cerebrospinal fluid from it at the time 
of the injury and thus indicative of a fracture of the base of the skull in this 
area ; in so many patients, this impairment of hearing is only a temporary 
one — usually not of longer duration than 12 to 18 months. 

Case 117. — Old severe brain injury associated with a fracture of the 
vault and of the base of the skull and with signs of an increased intracranial 
pressure ; continuous severe headache and spells of petit mat. Left subtem- 
poral decompression. Recovery. 

No. 292. — Father Francis. Forty-three years. White. Single. Mission- 
ary Priest. France. 

Admitted June 12, 1915 — 10 years after injury. Polyclinic Hospital. 
Referred by Doctor A. B. Duel. 

Operation June 22, 1915. Left subtemporal decompression and drainage. 

Discharged July 7, 1915 — 15 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Ten years ago while work- 
ing among the Indians in the Canadian Northwest, patient was in a runaway 
accident in which he was kicked upon the head, left lower jaw fractured 
and 3 ribs of the left side of his chest broken ; patient remained unconscious 
for one week with no special medical attendance ; profuse bleeding from the 
left ear ceased after 3 days ; gradual recovery from the acute condition, and 
after 5 months patient was able to resume his work in a less active capacity ; 
he always complained, however, of a dull heavy feeling in the head, spells 
of dizziness and at times a severe headache. Two years ago, during a spell 
of dizziness, patient ' ' fainted 5 ? momentarily and since that time these lapses 
of consciousness of the petit mal type have occurred almost daily; severe 
frontal and left temporal headaches have increased in frequency and in 
intensity so that he has been obliged to give up his work during the past 
18 months ; after any exertion such as walking, a severe pain in the left 
frontal and left temporal region occurs and will continue until the patient 
lies down and remains quiet for a period of 30 minutes or more. 

Two years ago, in the hope that the left labyrinth might have been in- 
volved and was a factor in causing the condition, a left radical mastoid 
operation was performed in Hartford but no marked improvement resulted. 
Five months ago, two trephine openings over the left front-parietal area 
were made in a hospital in Springfield in the "belief" that they would, 
in some way not to be explained, improve the condition ; merely 2 buttons 
of bone removed, the dura not opened and naturally no benefit was obtained 
(it is possible that an effort was being made to locate a fracture of tjie skull 
which, as is now well known, is possibly the most unimportant pari in the 
diagnosis and especially in the treatment of brain injuries). 

Examination upon admission (10 years after injury). — Temperature, 
98.8°; pulse, 68; respiration, 16; blood-pressure, 142. Well-nourished and 
developed; rather anxious facies; depressed and melancholic, fearing that 
he will never be able to return to his work. Mentality excellent. Exam- 



CHRONIC BRAIN INJURIES 473 

ination of head is negative, except for scars of former left mastoid operation 
and the two trephine openings over the left posterior frontal and left 
parietal areas, respectively ; no pulsation palpable. Hearing of the left ear is 
markedly impaired ; bone conduction is greater than air conduction. Pupils 
equal and react normally. Reflexes — patellar very much exaggerated, right 
possibly more active than left ; exhaustible right ankle clonus and suggestive 
right Babinski; abdominal reflexes — right less active than left. Fundi — 
retinal veins rather full ; nasal margins and a small portion of both nasal 
halves of optic disks obscured by edema; both physiological cups shallow 
from new tissue formation and a small amount of new tissue about the 
temporal margins of optic disks. Lumbar puncture — clear cerebrospinal 
fluid under increased pressure (approximately 15 mm.) ; Wassermann test 
negative and cell count was 4 cells per c.mm. X-ray (Doctor A. J. Quimby) — 
"left mastoid area blurred with new bone formation; irregular bony de- 
fects with new bone formation over the left frontal area posteriorly. Indis- 
tinct and irregular line of fracture extending transversely through the 
squamous portion of the left temporal bone. ' ' 

Treatment. — A left subtemporal decompression was considered advisable 
to lessen the increased intracranial pressure and thereby relieve the head- 
ache and thus possibly lessen the cortical irritability so that the spells of 
petit mat would cease, the vertigo* disappear and the patient be benefited. 

Operation (10 years after injury). — Left subtemporal decompression: 
rather high vertical incision, bone removed, and no complications; much 
fibrous tissue in the fibres of the temporal muscle, due probably to a former 
hemorrhage in the muscle itself beneath the temporal fascia ; this was con- 
firmed largely by finding an irregular transverse fracture ridge extending 
through the lower portion of the underlying squamous bone, in which situa- 
tion the underlying left middle meningeal artery could have been easily torn 
at the time of the fracture. Dura was thickened and under high tension ; 
upon incising it, much cerebrospinal fluid escaped, revealing a very ede- 
matous swollen cortex which tended to protrude but did not rupture. Slight 
hazy induration about the vessels in the sulci and in the arachnoid itself — ■ 
the residue of a former subarachnoid hemorrhage. No gross lesions in or 
upon the cortex visible. At the end of the operation, the cortex had receded 
and pulsated almost normally. No adhesions between arachnoid and the 
overlying dura observed. Usual closure with 2 drains of rubber tissue in- 
serted. Duration, 50 minutes. 

Post -operative Notes. — Uneventful operative recovery; within 4 days 
after operation, the dull heavy feeling in the head had lessened and patient 
said that "my head feels better than it has for months." Patient was dis- 
charged on the fifteenth day after operation; incision healed per primam. 

Examination (April 7, 1917 — 22 months after operation). — Patient has 
had only 6 spells of petit mal since the operation, although he has had almost 
each month an acute attack of dizziness and "heaviness" in the head but 
"nothing happens"; no longer has severe headache following mild exertion 
and is able to perform his duties at La Salette College, Hartford ; no longer 
is depressed and melancholic. Decompression area is slightly depressed and 
pulsates normally. Pupils equal and react normally. Reflexes active but. 





474 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

otherwise negative. Fundi — retinal veins possibly slightly enlarged ; slight 
edematous blurring of lower quadrant of nasal margins of both optic disks ; 
new tissue formation naturally persists in both physiological cups and along 
the margins of the optic disks. Second X-ray (Doctor A. J. Quimby) — 
* ' in addition to the first plate, the circular decompression opening is shown ' ' 
(Fig. 142). 

Last Examination (February 20, 1919 — 55 months after operation). — 
Patient has not had a ' ' fainting spell ' ' for 14 months and has only had 13 in 
all since the operation ; occasional headache of mild severity, but he is other- 
wise well and able to perform his duties daily ; no dizziness. Patient says : 
"Place where you operated is now always sunken in and I can feel it 
beating." Reflexes active but otherwise negative. Fundi negative, except 

for the new tissue formation. 
Remarks. — It would 
seem that a most satisfactory 
result had been obtained in 
this patient and that the 
operation to improve his 
condition was fully justi- 
fied. I am of the opinion, 
however, that he cannot be 
considered cured until a 
longer period of time has 
elapsed, although appar- 
ently he has now entirely 
recovered from the condition. 
It is hard to conceive that 
a patient can have even a 
small amount of fibrous 
residue upon the cortex re- 
sulting from a former sub- 
arachnoid hemorrhage and 
yet, even in the absence of a definite increase of the intracranial pressure, 
that the patient can be normal both mentally and physically, and also emo- 
tionally; this latter complication of emotional instability is most easily 
induced and the return to normal is most difficult. 

The former trephine openings and merely small " buttons" of bone 
removed and the dura not opened may justly be termed meddlesome surgery ; 
the purpose of such inadequate and even not exploratory operations are, to 
be sure, of very little risk to the patient (the dura not being opened), but 
also they are of no possible value to the patient; they may be termed 
"operations" and it may be added, "useless operations." The rontgeno- 
grams disclosing the bony defects and new bone formation in the left 
frontal area are interesting ; it would seem that a larger area of bone had 
been removed at the earlier operations. 

Case 118. — Old severe brain injury associated with a fracture of the 
base of the skull and with signs of an increased intracranial pressure; 




Fig. 142. — New bone formation following an old depressed 
fracture of the left frontal area in a patient with persisting 
symptoms and signs, which disappeared following a left sub- 
temporal decompression. 



CHRONIC BRAIN INJURIES 47 5 

convulsive seizures. Right subtemporal decompression. Improvement. 

No. 427. — John. Twenty-three years. White. Married. Mechanic. U. S. 

Admitted November 11, 1915 — 8 years after injury. Polyclinic Hospital. 
Referred by Doctor E. C. Douglas. 

Operation November 22, 1915. Right subtemporal decompression and 
drainage. 

Discharged December 19, 1915 — 27 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Eight years ago while play- 
ing baseball, patient was struck upon the right side of the head by a batted 
ball; no complete loss of consciousness — merely stunned, but owing to the 
severe headache he was unable to continue playing ; one hour later he walked 
home and lay down upon a couch; a small amount of watery fluid dis- 
charged from the right ear. Twelve hours later, a general convulsive seizure 
occurred, the patient remaining unconscious for 12 hours ; with the excep- 
tion of rather severe headaches, he made apparently a normal and unevent- 
ful recovery so that he was able to return to school after 10 days ; almost 
daily headaches, however, of mild severity continued, but the patient was 
considered well until 6 months later, when he had a second general con- 
vulsive seizure, and the third attack occurred 5 months later ; at this time, 
the condition was diagnosed as one of epilepsy and his treatment consisted 
of a small amount of bromide after each meal. The fourth convulsion 
occurred 6 months later, and since that time and during the past 6 years, 
the patient has had a general convulsive seizure every 3 to 6 months, until 
during the past year the attacks have increased in frequency to one every 
month of a severe character andj petit mal attacks on the average of one 
every 2 weeks; during the severe major attacks, patient has several times 
dislocated his right arm at the shoulder, but has required a doctor to 
reduce the dislocation only twice — being able to reduce it himself the 
other times. Beside the convulsive seizures, patient now complains of a 
dull heavy frontal headache, loss of ambition — * ' always tired, ' ' and unable 
to remember things, especially recent occurrences; he has been unable to 
work during the past 8 months — "nobody will take me." 

Examination upon admission (8 years after injury). — Temperature. 
98.6°; pulse, 76; respiration, 18; blood-pressure, 128. Well-nourished and 
developed. Mentality rather retarded and confused ; depressed and melan- 
cholic — "no hope for me." No external evidence of former head injury. 
Hearing negative ; air conduction greater than bone conduction in both ears ; 
otoscopic examination negative. Pupils equal and react normally. Re- 
flexes — patellar very much exaggerated but equal; no ankle clonus nor 
Babinski ; abdominal reflexes both depressed but equal. Fundi (Doctor 
J. A. Kearney) — "vision normal, media clear, disks circular; temporal 
margins of disks distinct, while nasal halves are blurred by edema ; retina! 
veins engorged. Irregular heaping of pigment interspersed with lighter 
streaks over entire fundus ; both eyes about the same. ' ' Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (approximately 16 mm.) ; 
Wassermann test negative and cell count was 7 cells per c.mm. X-ray (Doctor 
A. J. Quimby) — "no sign of fracture visible." 



476 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Treatment. — The definite history of cranial injury sufficient to cause a 
discharge of cerebrospinal fluid from the right ear and therefore associated 
with a fracture of the base of the skull, and followed within 12 hours by a 
convulsive seizure which has recurred at varying intervals during the 
past 8 years with increasing frequency and severity, and now the demon- 
stration of an increased intracranial pressure by the ophthalmoscope and 
at lumbar puncture — these data make the operation of cranial decompression 
advisable and especially so since the patient has had competent medical 
treatment — at least during the past 6 years. 

Operation (8 years after injury). — Right subtemporal decompression: 
usual incision, bone removed, and no complication. Dura very much thick- 
ened and under moderate tension: upon incising it. clear cerebrospinal 
fluid welled out. and upon enlarging the dural opening the underlying cortex 
bulged markedly: over the entire cortex exposed was a cloudy grayish 
cystic formation, at least one-fourth inch in thickness — most probably result- 
ing from the organization of a former subdural hemorrhage; upon "knick- 
ing" this cystic formation, a pale straw-colored fluid escaped, permitting 
the cyst to collapse : an area of over one inch of its outer wall was excised. 
About the supracortical vessels in the sulci and in the arachnoid itself was 
a cloudy induration of new tissue formation — the residue of a former sub- 
arachnoid hemorrhage. At the end of the operation, the cortex had receded 
sufficiently to pulsate almost normally, so that the closure of the overlying 
temporal muscle was facilitated. Usual closure with 2 drains of rubber tissue 
inserted. Duration, one hour. 

Post-operative Xotes. — Convalescence very stormy in that a post-opera- 
tive pneumonia of the right lung developed on the third day and in addition 
the diagnosis of either an hepatic or subdiaphragmatic abscess was made, but 
the latter diagnosis could not be confirmed : patient under care of Doctors 
Alexander Lyle and Ernest Bishop and after an eventful period of 2 weeks, 
he made an excellent recovery so that he was discharged on the twenty- 
seventh day after operation. No convulsions occurred during the hospital 
residence, although patient complained of a dull frontal headache through- 
out this period ; at discharge, the decompression area bulged rather tensely 
beyond the flush of scalp but it pulsates normally. 

Examination (April 10, 1917 — 17 months after operation). — Patient 
has had in all only 7 major convulsive seizures and 10 minor spells with 
only momentary loss of consciousness; he has improved markedly both 
mentally and emotionally, works daily, and with the exception of the occa- 
sional seizure of dull headache, patient considers himself ' ' in fine condition. ' ' 
Reflexes active but otherwise negative. Fundi — retinal veins slightly en- 
larged; both fundi rather edematous but not localized to the optic disks, 
which are clear and distinct. Decompression area slightly depressed beneath 
the flush of scalp and pulsates normally. 

Last Examination ( February 5. 1919 — 39 months after operation). — 
A major convulsive seizure now occurs on the average of once every 11 weeks 
and a petit mal attack about once a month ; the effect of these spells upon 
the patient does not appear to be very harmful (as before the operation), in 
that the patient is only ' ' knocked out, ' ' as he says, for a period of one to two 



CHRONIC BRAIN INJURIES 477 

hours — he then being able to resume his work and with no real discomfort ; 
the headache is never severe — "they don't bother me at all." Decompres- 
sion area slightly depressed beneath flush of scalp and the pulsation is 
normal. Reflexes active but otherwise negative. Fundi — retinal veins still 
slightly enlarged; both retinas suffused and congested, but no edematous 
blurring of details of optic disks themselves. 

Remarks. — In this patient, the convulsive condition has undoubtedly 
been improved and at least delayed, but at any moment and within the 
near future this patient may develop a series of convulsive seizures and 
rapidly deteriorate. In the majority of patients, and especially of this 
type where there still persists undoubtedly a chronic cerebral edema, both 
resulting from the convulsions themselves and due also to the irritative 
presence of the supracortical residue of the former hemorrhage — in these 
patients the danger of an increased frequency and severity of the convulsions 
is very great indeed ; it would seem that in some of these patients there is 
present a mild external hydrocephalus (and thus the cause of the chronic 
cerebral edema), due to a partial blockage of the excretion of the cerebro- 
spinal fluid through the normal stomata of exit in the cortical veins, sinuses, 
etc., which have become blocked to a greater or less extent by the new 
tissue formation resulting from the organization of the supracortical hemor- 
rhage. It might be advisable to perform a bilateral decompression upon 
patients of this character when or in whom a unilateral decompression 
does not seem to be sufficient both in relieving the increased intracranial pres- 
sure and as a means of increased drainage of the blocked cerebrospinal fluid. 

Case 119. — Old severe brain injury associated with a fracture of the skull, 
and with signs of an increased "intracranial pressure ; convulsive seizures. 
Left subtemporal decompression. Improvement. 

No. 447. — John. Thirty-one years. White. Married. Policeman. U. S. 

Admitted November 16, 1915 — 3y 2 years after injury. Polyclinic Hos- 
pital. Referred by Doctor J. W. Brannan. 

Operation December 1, 1915. Left subtemporal decompression and 
drainage. 

Discharged December 21, 1915 — 20 days after operation, 

Family history negative. 

Personal History.— Always, well and strong; of good habits. Three 
and a half years ago (June 12, 1912), while riding to a fire as a mounted 
policeman, patient was thrown from his horse ; immediate loss of conscious- 
ness ; profuse bleeding from right ear ; taken to the Flushing Hospital in an 
ambulance and a depressed fracture of right frontal bone removed (dura. 
however, not being opened); patient remained unconscious for 19 days, 
gradual recovery occurred so that he was finally discharged from the 
hospital in September, 1912 (3 months after injury"), and appeared to be in 
good condition. Patient was able to return to his work on "light duty" 
and with the exception of almost daily headaches of moderate severity, 
he considered himself well. Twelve mouths after injury (2 1 - years ago), 
the first general convulsive seizure occurred with loss of consciousness, 
biting of tongue and sphincteric relaxation ; headaches increased both 
in frequency and severity after the convulsive seizure and he began 



478 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

to ' ' lose interest in things. ' ' The second convulsion occurred 2 months later, 
and during the past 2 years a major convulsion has occurred on an average 
of every 6 weeks or 2 months ; definite mental and emotional impairment, 
so that the patient has been unable to work during the past 6 months ; he has 
lost all confidence in himself and becomes so irritable that his relatives 
find it very difficult to live in the same house with him. There is an indefi- 
nite history that the convulsions always begin on the right side of the body, 
either in the right arm or right leg. but no competent observer confirms this. 

Examination upon admission {dy 2 years after the injury). — Tempera- 
ture, 98.8° ; pulse, 72; respiration, 16; blood-pressure, 144. Well-developed 
and nourished ; very much depressed and says ' ' I want to end it all. ' ' Over 
the right frontal area is an irregular scar and a slight depression of a bone 
defect : no pulsation palpable. Hearing negative ; air conduction greater 
than bone conduction in both ears ; indefinite and irregular thickening of 
posterior portion of right tympanic membrane — scar tissue of a former 
laceration in this area at the time of the head injury. Pupils equal and react 
normally. Reflexes — patellar active but equal ; no ankle clonus but sugges- 
tive right Babinski ; abdominal reflexes — right possibly less active than left. 
Fundi — retinal veins enlarged; nasal margins of both optic disks blurred, 
but other details of optic disks clear and distinct. Lumbar puncture — clear 
cerebrospinal fluid under increased pressure (approximately 14 mm.) ; AVas- 
sermann test negative and cell count was 4 cells per c.mm. X-ray (Doctor 
A. J. Quimby) — "irregular bony defect of 3 cm. in diameter in right frontal 
area ; new tissue formation about the* periphery and over the underhung 
dura. No line of fracture can be seen. ' ' 

Treatment. — The definite history of cranial injury followed within 
a year by convulsive seizures and associated, as now demonstrated, by an 
increased intracranial pressure and the neurological examination revealing 
signs indicative of a lesion affecting the left hemisphere possibly more than 
the right — these data made a left subtemporal decompression advisable in 
the hope that the convulsive seizures might thus be lessened, the headache 
relieved and the general condition of the patient be improved. 

Operation (3% years after injury). — Left subtemporal decompression: 
usual vertical incision, bone removed, and no complications. Dura thickened, 
vascular and very tense ; upon incising it, clear cerebrospinal fluid spurted 
to a height of one inch ; upon enlarging the dural opening, there were exposed 
and severed many adhesions between the cortex and the overlying dura and 
in the upper portion of the left temporal lobe was an old laceration of the 
cortex extending backward beyond the posterior edge of the bony decom- 
pression opening; a bluish cystic mass lay within the cortical laceration 
and over the lower half of the left temporal lobe was a bluish cystic for- 
mation — the size of a silver quarter : both these hemorrhagic cysts were in- 
cised, allowing a straw-colored fluid to escape. Many adhesions were severed 
as widely as possible about the decompression area. At the end of the opera- 
tion, the cortex had receded and pulsated almost normally. Usual closure 
with 2 drains of rubber tissue inserted. Duration. 45 minutes. 

Post-operative Xotes. — Uneventful operative recovery; no convulsions 
occurred during hospital residence and at discharge on the twentieth day 



CHRONIC BRAIN INJURIES 



*79 



after operation, the headache was less than at any time during the preceding 
6 months ; incision healed per primam. 

Examination (January 10, 1917 — 13 months after operation). — Patient 
has had six general convulsive seizures since leaving the hospital — five of 
these occurring within the first seven months. Patient has been on "light 
duty" during the past 6 months, no longer complains of severe headaches 
and his general mental and emotional condition has so improved that his 
wife says "he is like his ownself again." Decompression area is definitely 
depressed and the pulsation is normal. Reflexes active but otherwise nega- 
tive. Fundi — retinal veins of normal size; both optic disks clear and dis- 
tinct but surrounding retinae are slightly suffused and congested with a 
"pepper-pot" appearance (report of Doctor J. A. Kearney). A second 
X-ray by Doctor A. J. 
Quimby — "similar appear- r 
ance as in former rontgeno- 
gram with addition of the 
left decompression bony de- 
fect" (Fig. 143). 

Last Report (November 
16, 1918—35 months after / 

operation) . — D u r i n g the 
past 2 years, patient has had 
a general convulsive seizure 
every 4 months; these at- 
tacks are not as severe as 
formerly and their effect 
does not last longer than 2 
hours. Patient is still on 
"light duty" and as the 
spells usually occur at night, 
his work is thereby not 
affected. No complaints of 
severe headache, and if it 
were not for the convulsive seizures he would consider himself a ' ' well man. ' ' 

Remarks. — The pathology of cortical laceration as revealed at the left 
subtemporal decompression would make it appear that this lesion was one 
of contre-coup in that the area of contact was in the right frontal region at 
the site of the depressed bone. These contre-coup brain injuries are of com- 
mon occurrence, and it is of importance in each case to examine the patient 
neurologically most carefully in the hope that if there is present an increased 
intracranial pressure making a subtemporal decompression advisable, then 
there will be ascertained signs pointing to the hemisphere more involved. 
The chief function of the operation, however, is naturally to lessen the 
increased intracranial pressure and if possible upon the side more affected; 
if there are no localizing signs to be elicited, then the right subtemporal 
decompression is to be preferred in right-handed patients and thus the 
slight danger of any possible damage to the neighboring motor speech area in 




Fig. 143. — Large irregular bony defect of right frontal aiea, 
following a depressed fracture and associated with convulsive 
seizures. Marked improvement following the lowering of the 
increased intracranial pressure by means of a left subtemporal 
decompression. 



4 8o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the left cerebral cortex be avoided; usually in right-handed patients, and 
particularly if the parents and grandparents were also right-handed, then 
the motor speech area is usually in the posterior portion of the third left 
frontal convolution (Broca's motor speech center). 

This patient has been undoubtedly improved as the result of the opera- 
tion, but whether the improvement will continue over a longer period of 
years cannot be assured ; he naturally should lead a rather careful hygienic 
life with no prolonged mental and emotional strains, and a restricted light 
diet with no meat or meat soup, tea, coffee, and particularly alcohol — that is, 
a vegetarian diet with the addition of not more than 2 eggs a day, 2 glasses of 
milk and the white of chicken not more than twice a week ; fish is permissible. 

Case 120. — Old severe brain injury associated with a fracture of the 
occipital bone and with signs of an increased intracranial pressure ; convul- 
sive seizures. Right subtemporal decompression. Improvement. 

No. 1004. — James. Twenty-three years. White. Single. Mechanic. U. S. 

Admitted August 1, 1918 — 10 years after injury. Polyclinic Hospital. 
Referred by Doctor Charles Coburn, Philadelphia. 

Operation August 12, 1918. Right subtemporal decompression and 
drainage. 

Discharged August 31, 1918 — 19 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Ten years ago, patient was 
struck over the head by a baseball bat ; only momentary loss of consciousness 
and a trickling of clear watery fluid from the right ear ; he was able to walk 
home, and after 4 days there were no complaints. Patient was considered 
a normal child until 5 years ago (that is, 5 years after the head injury), 
when the first general convulsive seizure occurred; no localizing signs and 
no definite persistent complaint of headache or other symptoms ; the second 
general convulsion occurred 6 months later, and the third convulsive seizure 
followed in 4 months. During the past 4 years, these convulsive seizures 
of general character have increased both in severity and frequency, so that 
they are occurring now every 4 to 6 weeks — the last spell being 2 days 
ago. During the past 6 months, patient had an indefinite headache of 
moderate severity; he has become emotionally unstable, sluggish mentally 
and unable to work during the past 3 months. The patient has had compe- 
tent medical treatment. 

Examination upon admission (10 years after injury). — Temperature, 
98.6° ; pulse, 78 ; respiration, 20 ; blood-pressure, 132. Fairly well-developed 
and nourished ; general mental and emotional condition unusually good for 
a patient who has had convulsive seizures during a period of 5 years. No 
external evidence of cranial injury. Hearing less acute in right ear — bone 
conduction being almost equal to air conduction in the right ear ; otoscopic 
examination negative. Pupils equal and react normally. Reflexes very 
active but otherwise negative. Fundi— retinal veins slightly enlarged; 
indistinct edematous blurring of the lower nasal margins of both optic disks. 
Lumbar puncture — clear cerebrospinal fluid under increased pressure (14 
mm.) ; Wassermann test negative and cell count was 4 cells per c.mm. X-ray 



CHRONIC BRAIN INJURIES 



481 



(Doctor G. W. Welton) — "two distinct and irregular lines of fracture in 
the right occipital bone" (Fig. 144). 

Treatment. — The definite history of cranial injury sufficient to fracture 
the skull so that cerebrospinal fluid escaped from the right ear and then 
followed, after an interval of 5 years, by general convulsive seizures of 
increasing severity and frequency, the condition not being improved by 
competent medical treatment, and now the signs of an increased intracranial 
pressure being present and the former fracture of the skull confirmed by 
rontgenograms — the only chance apparently that this patient has of being 
improved or the condition being delayed or retarded is by means of a sub- 
temporal decompression to lessen mechanically the increased intracranial 
pressure and thus diminish the cortical irritability — at least temporarily. 
The patient being right-handed as were also his parents and grandparents, 
and there being no localiz- 
ing signs ascertainable by 
careful neurological exami- 
nations, the subtemporal de- 
compression was performed 
on the right side of the skull. 

Operation (10 years 
after injury). — Right sub- 
temp oral decompression : 
usual vertical incision, bone 
removed, and no complica- 
tions. Dura very thick, 
whitish and tense ; upon in- 
cising it, clear cerebrospinal 
fluid spurted to a height of 
2 cm. and upon enlarging 
the dural opening, the un- 
derlying cerebral cortex 
bulged but did not rupture 
owing to the rapid escape of much cerebrospinal fluid. Cortex very much 
congested and very edematous with much new-formed tissue in sulci and in 
the overlying arachnoid — the residue of a former subarachnoid hemorrhage. 
No gross cortical laceration or hemorrhagic cyst visible. At the end of the 
operation, the cortex had receded and pulsated normally. Usual closure 
with 2 drains of rubber tissue inserted. Duration, 35 minutes. 

Post-operative Notes. — Uneventful operative recovery; no convulsions 
during the hospital residence and the patient was discharged on the nine- 
teenth day after operation; incision healed per prima))}. 

Last Report (January 12, 1919 — 5 months after operation — letter from 
mother). — Patient had one general convulsive seizure of light character 
2 months after operation ; after one hour, he was able to continue his work 
and did not complain of the usual headache, nausea or vomiting. Since then, 
he has had no complaints and works daily. 

Remarks. — This recent case is reported to emphasize the necessity of 
most careful neurological examinations in order to ascertain definitely 
31 




Fig. 144. — Two irregular linear fractures of right occipital 
bone in a patient following an old cranial injury with convul- 
sive seizures. Definite improvement following a right sub- 
temporal decompression. 



482 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

whether the convulsive seizures are of the so-called idiopathic type (and 
they usually are), in which no> definite organic lesion can be considered an 
etiological factor and for this type of epilepsy little if anything can be 
offered, or if there is a definite organic lesion, intracranial or otherwise, 
which is the primary cause of the condition. In a small percentage of these 
patients having convulsive seizures, there are, just as in this patient, signs 
of an increased intracranial pressure and these patients alone are the only 
ones upon whom a cranial decompression can be considered, and especially 
if the original cause of the condition was a brain injury, tumor, etc. The 
increased pressure, however, may be secondary to frequent convulsive 
seizures which have caused a mild cerebral edema, but this can be decided 
in most patients by preventing the convulsions from occurring for a period 
of 4 to 6 weeks by the vigorous use of bromides, etc., and then if the oph- 
thalmoscope and the spinal mercurial manometer still demonstrate the pres- 
ence of a definite increase of the intracranial pressure, then this pressure 
must be considered as a primary factor rather than a secondary one to 
the convulsive seizures. 

This patient was at no time carefully examined neurologically during the 
5 years preceding the operation — he was considered merely ' ' an epileptic ' ' 
and no credence given to the possibility that the former cranial injury 
might have been a factor in producing the condition ; no careful ophthalmo- 
scopic examinations were at any time made and by no means a lumbar punc- 
ture and especially the registration of the pressure of the cerebrospinal 
fluid. (There is still a belief among many physicians that a lumbar puncture 
is a dangerous procedure and should only be resorted to in the presence 
of an acute severe illness where the immediate danger is great — as in menin- 
gitis and similar conditions. A lumbar puncture, properly performed 
with the usual asepsis and regard for removing only a small amount of the 
cerebrospinal fluid for cytological examinations and the Wassermann test, 
is not a dangerous procedure and should always be performed for any intra- 
cranial condition or disease, or supposed disease of the cerebrospinal 
system. ) If an X-ray had been taken, naturally more attention would have 
been given to the history of the former injury, but merely because most of 
vis have had a cranial injury of greater or less severity in our youth and 
no convulsions result and also almost all patients having the so-called 
idiopathic epilepsy have similar histories of cranial injuries which are not the 
cause of the convulsive seizures, it is very natural for the medical profes- 
sion to become very sceptical regarding cranial traumata as a factor in the 
production of convulsive seizures, but these patients having definite cranial 
injuries should at least be given the benefit of careful neurological exam- 
inations and particularly in respect to the presence or not of an increased 
intracranial pressure by careful ophthalmoscopic examinations and, most 
accurate of all, the measurement of the pressure of the cerebrospinal 
fluid at lumbar puncture by means of the spinal mercurial manometer. No 
patient having convulsive seizures should be considered carefully and 
competently examined, unless a lumbar puncture has been performed and 
both the pressure and cytological character of the cerebrospinal fluid have 
been made. It is granted that patients having idiopathic epilepsy in the. 



CHRONIC BRAIN INJURIES 483 

preconvulsive stage may have the motor convulsive seizures precipitated by 
a cranial injury of greater or less severity and naturally in these patients 
a differential diagnosis is very difficult and, undoubtedly at times, impossible, 
especially if the signs due to the cranial injury complicate the picture of an 
idiopathic type of epilepsy. 

This case is of too recent date to permit an opinion regarding the ultimate 
prognosis, but it is encouraging that 5 months could have elapsed with only 
one convulsion occurring. A further report of this patient will be made 
later in detail. 

b. No marked improvement. 

Case 121. — Old severe brain injury associated with a fracture of base 
of skull and with signs of an increased intracranial pressure ; severe headache 
and convulsive seizures. Left subtemporal decompression. Improvement of 
headache but only a temporary lessening of the convulsions. 

No. 245.— Abe. Fifteen years. White. Student. U. S. 

Admitted January 31, 1914 — 6 years after injury. Polyclinic Hospital. 
Referred by Doctor A. F. Stoloff. 

Operation February 5, 1914. Left subtemporal decompression and 
drainage. 

Discharged February 14, 1914 — 8 days after operation. 

Family history negative. 

Personal History. — Always well and strong. Six years ago, patient was 
struck over the head by a large glass decanter ; only momentary loss of con- 
sciousness and was able to walk home; complained of severe headache 
and dizziness; blood-tinged watery fluid discharged from the left external 
auditory canal for a period of only 24 hours ; patient was able to go to school 
the following day and after one week, he no longer complained of head- 
ache. Two months later, the first general convulsive seizure occurred; 
within 2 years, however, patient was having as many as 3 or 4 convulsions 
each night — almost all of them being nocturnal. During the past 2 years, 
the convulsive seizures frequently began in the right hand or in the right side 
of the face and then became general in character; he has had as many 
as 8 within 24 hours. During the past 6 months, patient has complained 
of persistent frontal headache and within the last 3 months, there has devel- 
oped a definite paraphasia. Competent medical treatment has been of 110 
benefit to the patient. 

Examination upon admission (8 j^ears after injury). — Temperature, 
98.8°; pulse, 74; respiration, 18; blood-pressure, 126. Well-developed and 
nourished. Except for a scar over the left posterior frontal area, there are 
no other signs of former cranial injury. Hearing negative ; otoscopic exam- 
ination negative. Definite weakness of right arm, but no weakness of the 
right side of face or of the right leg. Some paraphasia in that the patient 
cannot repeat the test phrases correctly. Pupils equal and react normally. 
Reflexes — patellar very active, right greater than left ; no ankle clonus but 
tendency to right Babinski ; abdominal reflexes — right depressed. Fundi — 
retinal vessels dilated ; nasal margins of both optic disks obscured by edema : 
no new tissue formation observed. Lumbar puncture — clear cerebrospinal 
fluid under increased pressure (approximately 15 mm.) ; Wassermann test 



484 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

negative and cell count was 4 cells per c.mm. X-ray (Doctor A. J. Quimby) 
— ' ' no fracture of the skull observed. ' ' 

Treatment. — A left subtemporal decompression was considered advisable 
in the hope that a lessening of the increased intracranial pressure would per- 
mit an improvement not only of the headache but also of the convulsive 
seizures ;' although the chances were against the patient being permanently 
benefited, yet the operation was considered justified even at this late date, and 
naturally, since the patient had had so many convulsive seizures, the prog- 
nosis was most grave. 

Operation (6 years after injury). — Left subtemporal decompression : 
usual vertical incision (slightly anterior), removal of bone, and no compli- 
cations; bone itself was unusually thick and vascular. Dura thickened, 
fibrous and very tense ; upon incising it, the underlying edematous cortex 
tended to protrude ; upon enlarging the dural opening, bluish white areas of 
organized blood-clot were exposed in the sulci about the vessels, being appar- 
ently fibrous and cystic formations — the residue of a former subarachnoid 
hemorrhage ; numerous adhesions between the arachnoid of cortex and the 
overlying dura, and these were severed as widely as possible. The escape 
of cerebrospinal fluid permitted the cortex to recede and to pulsate almost 
normally. Usual closure with 2 drains of rubber tissue inserted. Duration, 
45 minutes. 

Post-operative Notes. — Uneventful operative recovery ; except for a ' ' ful- 
ness ' ' in the head, the patient had no complaints ; he was discharged on the 
eighth day post-operative — no convulsions having occurred; incision healed 
per primam. 

Examination (March 20, 1915 — 13 months after operation). — Patient 
did not have a convulsive seizure until 3 months ago (10 months after opera- 
tion), when the first spell occurred while he was performing upon the 
stage ; since then, 2 other convulsive seizures have occurred at night in 
bed. Patient feels well, as he no longer has severe headaches nor dizziness; 
also no trouble with speech. No distinct weakness of the right arm can be 
ascertained. Decompression area is flush with the surrounding scalp and 
pulsates normally. Reflexes — patellar very active, right possibly being 
slightly greater than left ; no ankle clonus nor Babinski ; abdominal reflexes 
present and equal. Fundi — retinal vessels slightly enlarged; lower nasal 
margins of both optic disks only slightly blurred by edema. 

Examination (October 16, 1917 — 44 months after operation). — Patient 
has had. a stormy period during the past 2 years; although he has 
not complained of headache and has been able to work upon the stage 
regularly, yet a convulsive seizure occurs on an average of once every 3 
weeks ; the after-effects, however, are of only short duration and the patient's 
mental and emotional make-up has apparently not been damaged. Decom- 
pression area is only slightly depressed beneath flush of scalp and patient 
says it bulges at times ; normal pulsation. Reflexes — patellar very active, 
right still possibly a little more active than left ; otherwise negative. Fundi — 
retinal veins slightly enlarged ; the indefinite edematous blurring of the lower 
nasal margins of both optic disks is still present. 

Last Report (December 2, 1918 — 58 months after operation). — During 



CHRONIC BRAIN INJURIES 485 

the past year, patient has had 2 severe attacks of acute nephritis and during 
each of these periods, the convulsive seizures have become much more severe 
and frequent. He no longer suffers from headache and is able to per- 
form upon the stage. " If it were not for the convulsions, I would be a well 
man. The wound never really sinks in. ' ' 

Remarks. — The ultimate prognosis for this patient is naturally bad. 
The operation undoubtedly delayed and retarded the progress of the con- 
vulsive seizures and the headache has been relieved, but a rapid return of 
the frequency and severity of the convulsions may be expected, and espe- 
cially when complicated by the condition of nephritis. As the increased 
intracranial pressure has not been entirely relieved by the operation of 
decompression (unilateral), in that the operative area never became really 
depressed as it should have become within 6 months after the operation and 
to a depth of usually 1 cm., it might have been advisable to have performed 
a bilateral decompression within a year following the first operation and 
this greater relief of the increased intracranial pressure might have obtained 
a better result ; if a similar patient should present himself now, I should 
advise this method of procedure. Taken in all, however, this patient was 
hardly a fair test for the operation in that his condition was a rather 
extreme one and the operation was advised merely to give him a chance 
of improvement rather than offering him definite and permanent relief ; the 
history of three and four convulsive seizures each night during a 
period of two years makes the prognosis most grave — no matter what the 
treatment. Up to the present time, however, the condition has certainly 
not progressed. 

The right hemiparesis and paraphasia were probably due to a localized 
cerebral edema of the left cortex; it is noteworthy that this impairment 
has not returned since the left subtemporal decompression. 

Case 122. — Old severe brain injury associated with a possible fracture 
of the base of the skull and with signs of an increased intracranial pressure : 
severe headache and convulsive seizures. Right subtemporal decompression. 
Temporary improvement only. 

No. 574. — Joseph. Thirty-eight years. White. Married. Mechanic. U. S. 

Admitted April 4, 1916 — 7 years after injury. Polyclinic Hospital. Re- 
ferred by Doctor E. S. Bishop. 

Operation April 14, 1916. Right subtemporal decompression and 
drainage. 

Discharged May 2, 1916 — 18 days after operation. 

Family history negative. 

Personal History. — Always well and strong ; of good habits and no alco- 
holism. Seven years ago while at work, patient was struck over the right 
side of the head by a large wooden beam ; immediate loss of consciousness ; 
profuse bloody and later a "watery " discharge from the right ear ; taken to a 
hospital where he remained for 3 weeks, when he had so recovered that lie 
was discharged as "well." During the next 4 years, he was able to work 
but not so vigorously as before the injury — complained almost daily of 
frontal and occipital headaches, " light-headed' ' spells upon stooping, and 
became easily fatigued. Two and a half years ago after a severe headache 



486 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






lasting 2 days, patient "fainted" momentarily but he did not fall to the 
ground; since that time, these "fainting" spells have occurred with increas- 
ing frequency so that, during the past 3 months, he has had as many 
as 11 attacks in one day ; they occur chiefly during exertion and in the late 
afternoon — toward the end of a hard day's work. No major convulsive seiz- 
ures have occurred at any time, although there is a history of having 
awakened 3 times in the morning to find that he had bitten his tongue and 
urinated involuntarily; headaches have become severe and he is now 
morose and melancholy; no longer takes an interest in current events; has 
been unable to work during the past 2 months. Patient has had competent 
medical treatment. 

Examination upon admission (7 years after injury). — Temperature, 
98.6° ; pulse, 68 ; respiration, 18 ; blood-pressure, 144. Fairly well-developed 
and nourished ; very much depressed and only answers questions upon insist- 
ence. No tremor of the tongue, lips or hands. No external evidence of 
former cranial injury. Hearing negative; otoscopic examination negative. 
No paralyses or impairments of sensation. Pupils equal and react nor- 
mally. Reflexes — patellar very much exaggerated ; exhaustible ankle clonus 
but no Babinski; abdominal reflexes both depressed but equal. Fundi — 
retinal veins dilated; nasal halves of both optic disks blurred by edema; 
no new tissue formation visible. Lumbar puncture — clear cerebrospinal 
fluid under increased pressure (approximately 15 mm.) ; Wassermann test 
negative and cell count was 7 cells per c.mm. X-ray (Doctor W. H. Stewart) 
— "no fracture of the skull." 

Treatment. — Although no major convulsive seizures have occurred, the 
history of this patient, especially during the past 2 years and the increasing 
number of spells of the petit mal character, and the condition associated 
with definite signs of an increased intracranial pressure — these data would 
give the impression that the symptoms and signs of headache, dizziness and 
minor epileptiform spells were but the forerunners of convulsive seizures of 
the major type, and for this reason and in order, if possible, to prevent con- 
vulsions from occurring, the operation of right subtemporal decompression 
was advised — the patient, his parents and grandparents being right-handed 
and there being no localizing signs ascertained. 

Operation (7 years after injury). — Right subtemporal decompression: 
usual vertical incision, bone removed, and no complications. Dura thick- 
ened, whitish, very vascular and under moderate tension; upon incising it, 
clear cerebrospinal fluid welled out, and throughout the operation the largest 
amount of cerebrospinal fluid escaped that I have yet seen ; consequently the 
underlying cortex, owing to this rapid escape of cerebrospinal fluid, did not 
bulge and it pulsated normally. The cortex itself was very ' ' wet ' ' and ede- 
matous; several adhesions between the arachnoid and the overlying dura 
were severed. No gross pathological lesions visible — only a very "wet," 
edematous brain. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 40 minutes. 

Tost -operative Notes. — Uneventful operative recovery ; operative incision 
healed per primam; patient did not complain of a "fainting" spell during 



CHRONIC BRAIN INJURIES 



487 



his hospital convalescence and was discharged on the eighteenth day after 
operation. A second X-ray report — "bony defect of decompression opera- 
tion with four silver clips demonstrated" (Fig. 145). 

Examination (November 20, 1917 — 19 months after operation). — During 
the first 3 months after operation, patient was so improved that the head- 
aches were lessened and the petit mal attacks so infrequent that it was hoped 
that he would be able to return to work; after working one week, the losses 
of consciousness returned, the headache became severe and the sense of 
early fatigue so great that the patient was obliged to give up work and has 
not worked since. In addition to the increasing frequency of the ' ' fainting" 
spells, there has been a mental and emotional deterioration, so that now it is 
not possible for the patient to leave the house alone, and he has become 
so depressed and despondent that he sits for hours at a time by himself ; he 
rarely speaks. For no reason apparently, tears will course down the patient 's 
cheeks and even crying spells lasting over an hour occur ; in many respects, 
the condition is similar to 
one of traumatic dementia. 
Decompression opening de- 
pressed and pulsates nor- 
mally. Reflexes active but 
otherwise negative. Fundi 
— retinal veins possibly 
slightly enlarged; no ede- 
matous blurring of optic 
disk margins but both retinae 
are rather suffused and ede- 
matous. 

Last Report (September 
20, 1918—29 months after 
operation) . — Wife writes 
that patient is now in an in- 
stitution as his condition 
gradually became worse so 
that he could not look after himself 
No major convulsions, however, had occurred 
remained depressed. 

Remarks. — It would seem that this patient had developed most rapidly 
the advanced form of traumatic dementia and whether there was an under- 
lying organic and constitutional basis for this marked mental and emotional 
deterioration cannot be stated; syphilis was not demonstrated as a factor 
nor were there ascertained any data of cardio-nephritic complications — in 
fact, no toxemic factor had been obtained. It is very surprising that no 
major convulsions have occurred in this patient, both on account of the 
history of the minor epileptiform spells of the petit })ial type and on account 
of the pathology of the cerebral cortex as revealed at operation. The post- 
mortem findings will be most important in ascertaining the other causative 
factor in this patient's condition, if there is one: the permission for an 
autopsy has been obtained in writing. 




_ Fig. 145.— Oval bony defect of right subtemporal decompres- 
sion in a patient following a fracture of the base of the skull 
and having signs of an increased intracranial pressure. Only 
temporary improvement following operation. 

even the most elementary things. 
Decompression area always 






4 88 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

E. Chronic Brain Injuries, not Associated with a Fracture of the 

Skull, with the Symptoms and Signs Persisting and Due to an 
Increased Intracranial Pressure. 

If there had been no increase of the intracranial pressure ascertained in 
this series of patients, then a number of them would have been considered 
either as conditions of post-traumatic neurosis (a diagnosis so common 
and so tempting to niake'i or as the result of cerebral lacerations and con- 
tusions, and thus irreparable. The presence of the increased intracranial 
pressure, however, immediately made these patients amenable at least to 
treatment — either medical, or if this method failed, then surgical treatment 
— and thus it was possible for them to be benefited. It is only these 
selected patients having an increased intracranial pressure who can be 
consistently improved. 

E. Old brain injuries not associated with a fracture of the skull but 
with signs of increased intracranial pressure : symptoms and signs persist- 
ing. Subtemporal decompression. Improvement. 

Case 123. — Old severe brain injury not associated with a fracture of the 
skull but with signs of an increased intracranial pressure : severe headaches 
and emotional disturbances. Right subtemporal decompression. Recovery. 

No. 343. — Barbara. Thirty years. White. Married. Housework. Russia. 

Admitted August 20. 1915 — 1 year after injury. Polyclinic Hospital. 
Referred by Doctor 0. S. Wightman. 

Operation September 3. 101-5. Right subtemporal decompression and 
drainage. 

Discharged September IT. 1915 — 11 days after operation. 

Family history negative. 

Personal History. — Always well and strong. One year ago. patient was 
struck over the head by a heavy club while being attacked by a burglar ; 
immediate loss of consciousness ; no bleedinT from either ear ; taken in an 
ambulance to a hospital, where she remained 2 weeks. Since discharge, 
patient has had a continuous dull headache with severe exacerbations : she 
has never * ' fainted ' ' nor has a convulsive seizure occurred. During the past 
3 months, the headaches have become so severe and associated with vomiting 
spells that the patient has been obliged to remain in bed. Competent medical 
treatment has been unable to relieve the headache which at first had been 
considered as being a post-traumatic neurosis and entirely neurasthenic in 
character. Patient has become very irritable and depressed. 

Examination upon admission 1 year after injury . — Temperature 9S.8 3 
pulse 70; respiration. IS: blood-pressure, 126. Rather poorly developed 
and nourished: very much depressed and melancholic. No external evidence 
of head injury. Hearing negative ; otoscopic examination negative. No 
paralysis or impairments of sensation. Pupils equal and react normally. 
No nystagmus. Reflexes — patellar very much increased but equal: no 
ankle clonus nor Babinski ; abdominal reflexes depressed but equal. Fundi 
— retinal veins rather full ; nasal margins of both optic disks blurred by 
edema but otherwise negative. Lumbar puncture — clear cerebrospinal fluid 
under increased pressure approximately 14 mm.' ; first \Yassemiann test 
1 plus: second and third \Vassermann tests negative: cell count was 7 cells 



CHRONIC BRAIN INJURIES 489 

per c.mm. X-ray (Doctor A. J. Quimby) — "no fracture of skull to 
be observed. ' ' 

Treatment. — In the belief that the severe headache was due to a chronic 
cerebral edema following the brain injury of 12 months ago and since com- 
petent medical treatment was unable to relieve the condition and there 
being present definite signs of an increased intracranial pressure, a right 
subtemporal decompression was advised not only to relieve the headache, but 
also thereby to lessen the emotional instability and to prevent the danger 
of future complications — particularly epileptiform seizures. (No doubt, 
there' is a large neurasthenic and neurotic factor in this case, but I believe 
it is superimposed upon and due to the definite organic lesion of chronic 
cerebral edema.) 

Operation (12 months after injury). — Right subtemporal decompression : 
usual vertical incision and bone removed ; while rongeuring away the bone, 
the middle meningeal artery was torn and much difficulty encountered in 
checking the rapid escape of blood ; it was finally stopped by the application 
of a silver clip, low down, at the inferior border of the decompression 
opening. Dura slightly thickened and tense ; upon incising it, clear cerebro- 
spinal fluid oozed out, revealing a very "wet," edematous cortex under 
increased pressure. The rapid escape of cerebrospinal fluid permitted the 
cortex to recede and pulsate normally before the end of the operation. No 
gross lesion visible and only a "wet," swollen edematous cortex exposed. 
Usual closure with 2 drains of rubber tissue inserted. Duration, 90 minutes. 

Post-operative Notes. — Uneventful operative recovery; within a week, 
the patient complained less of headache and at discharge on the fourteenth 
day post-operative, patient felt better than she had for months in that the 
headaches were not severe and she was not so depressed; incision healed 
per primam. 

Examination (November 22, 1917 — 26 months after operation). — Patient 
has been practically well since the operation ; during the past year, a dull 
headache occurred not more than once a month ; she is no longer irritable 
and depressed, and in every way l ' seem to be myself a^ain. ' ' Decompression 
area slightly depressed beneath the flush of scalp ; normal pulsation. Re- 
flexes active but otherwise negative. Fundi — retinal veins possibly slightly 
enlarged; no blurring of margins of optic disks and all details are clear 
and distinct. 

Last Report (December 14, 1918 — 39 months after operation). — Patient 
writes, "I am as well as ever; nothing bothers me now outside of an infre- 
quent headache but it's not much. Scar of operation sunken and I can 
feel it beating. ' ' 

Remarks. — From the history of this patient, and if careful ophthalmo- 
scopic and lumbar puncture examinations had not been made, it would have 
been very easy to have considered the patient as neurotic and neurasthenic — 
a condition of post-traumatic neurosis alone; and if there were no signs 
of an increased intracranial pressure, this diagnosis of a functional condition 
would have been the more probable one. But it having been ascertained 
that there was an increased intracranial pressure, then the diagnosis of sim- 
ple neurosis is not sufficient and unless medical treatment is able to lower 



4QO DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






this increased pressure (usually due to a chronic cerebral edema follow- 
ing the injury), the condition cannot be improved by the usual treatment 
of functional conditions, such as psychotherapy, etc. When the usual 
medical means do not suffice in lowering the increased intracranial pressure 
of these patients, then the mechanical relief of the pressure is necessary by 
means of a subtemporal decompression — not only to improve the present 
condition but also to prevent the even more serious complications, such as 
convulsive seizures, marked mental and emotional impairments, etc. 

The X-ray picture in not disclosing a fracture of the skull does not mean 
that a fracture of the skull had not been present ; unless the X-ray picture 
is taken at the proper angle to disclose the fracture (if present), then its 
shadow will not be seen and a picture at a different angle will frequently 
reveal its presence. However, as has been stated before, the fracture of 
the skull (unless it is a depressed fracture of the vault), is possibly the 
most unimportant part of brain injuries, and frequently the most serious 
brain injuries are not associated with a "fracture of the skull," which 
is a term meaning little or nothing — except that the cranial injury was 
of sufficient force to fracture the skull and very frequently patients having 
this condition are not at all seriously injured in that the brain has not 
been damaged in the least, whereas only too frequently a severe brain 
injury results when no fracture has occurred. 

Case 124. — Old severe brain injury not associated with a fracture of the 
skull but with signs of an increased intracranial pressure ; severe headaches, 
dizzy spells and emotional disturbances. Right subtemporal decompres- 
sion. Recovery. 

No. 855. — Mabel. Forty-five years. White. Married. Housewife. U. S. 

Admitted May 5, 1915 — 15 months after injury. Polyclinic Hospital. 
Referred by Doctor C. H. Chetwood. 

Operation May 16, 1915. Right subtemporal decompression and drainage. 

Discharged May 30, 1915 — 14 days after operation. 

Family history negative. 

Personal History. — Always well and strong; no alcoholism. Fifteen 
months ago, patient was struck upon the head by the falling of a heavy trap- 
door ; momentarily unconscious and remained in a semiconscious condition 
for 2 days ; no bleeding from the ears ; patient remained in bed at home for 
a period of 2 weeks, having severe headache and dizziness, which continued 
until 4 months ago, when the headache became so acute and the dizziness 
so extreme that the patient has been unable to walk any distance; marked 
increase of nervousness, so that the patient is very easily frightened; 
emotional upsets — crying spells and then very melancholic for several days 
at a time — always complaining of a severe headache; no "fainting" spells 
nor convulsive seizures at any time. Patient has had competent medi- 
cal treatment. 

Examination upon admission (15 months after injury). — Temperature 
98.6° ; pulse, 78 ; respiration, 20 ; blood-pressure, 138. Fairly well-developed 
and nourished; very anxious expression and complaining of severe frontal 
.and occipital headache. No external evidence of cranial injury. Hearing 
negative ; otoscopic examination negative. No paralyses or impairments of 



CHRONIC BRAIN INJURIES 491 

sensation. Pupils equal and react normally. No nystagmus. Reflexes — 
patellar exaggerated but equal ; no ankle clonus but suggestive double Babin- 
ski; abdominal reflexes obtained with difficulty. Fundi — retinal veins 
dilated ; nasal halves of both optic disks obscured by edema — right possibly 
more than left. Lumbar puncture — clear cerebrospinal fluid under increased 
pressure (approximately 16 mm.) ; Wassermann test negative and cell count 
was 3 cells per c.mm. X-ray (Doctor A. J. Quimby) — "the picture 
is negative." 

Treatment. — For fear that this patient might become so emotionally 
unstable that convulsive seizures would occur and there being a definite 
increase of the intracranial pressure as demonstrated by the ophthalmoscope 
and at lumbar puncture, and also since the routine treatment of general 
hygiene, diet, catharsis and the usual neurasthenic treatment of hydro- 
therapy, electrotherapy and psychotherapy have been of no benefit to the 
patient but the condition is becoming rapidly worse, it was decided to per- 
form a right subtemporal decompression in the hope that the condition 
would be improved by thus lessening the increased intracranial pres- 
sure mechanically. 

Operation (15 months after injury). — Right subtemporal decompression : 
usual vertical incision, bone removed, and no complications ; bone was un- 
usually thin and not vascular. Dura thin, transparent and bulging ; upon 
incising it, clear cerebrospinal fluid spurted out under high tension, and 
upon enlarging dural opening the underlying "wet," edematous cortex 
tended to protrude but did not rupture, as the cerebrospinal fluid escaped 
rapidly in large quantity so that the cortex soon receded and pulsated 
normally. No gross cortical lesion demonstrated except the very "wet" 
and almost cystic condition of the pia-arachnoid. Usual closure with 2 
drains of rubber tissue inserted. Duration, 35 minutes. 

Post -operative Notes. — Uneventful operative recovery; incision healed 
per primam; patient complained of only dull headache and he was able to 
be discharged upon the fourteenth day post-operative. 

Examination (October 4, 1916 — 17 months after operation). — Patient 
has made an excellent recovery ; although she has a dull headache almost each 
week, it no longer interferes with her work and it is not associated with 
dizziness ; i ' disposition ' ' is much better in every way — is seldom depressed 
and only occasionally irritable. Husband says she is now "livable." De- 
compression area depressed beneath the flush of scalp and pulsates nor- 
mally. Reflexes active but otherwise negative. Fundi — retinal veins of 
normal size ; details of both optic disks clear and distinct. 

Last Examination (September 4, 1918 — 40 months after operation"). — 
The improvement of the patient has continued so that she is considered a 
"well woman"; she has only an occasional mild headache and if it were nor 
on account of the fear that "my nervous fits" would return, patient saj s 
she would be perfectly happy; she is able to do her house-work. Decom- 
pression area depressed and pulsates normally. Reflexes active but other- 
wise negative. Fundi negative. 

Remarks. — This patient has been a very interesting one to follow and 
to note the marked change — especially the lessening of the signs of pressure 



492 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

in the fundi. If it were not for the signs of the increased intracranial 
pressure, this patient would have been considered as suffering from a post- 
traumatic neurosis and that would have undoubtedly been her condition; 
however, upon ascertaining the signs of an increased intracranial pressure 
by means of the ophthalmoscope and at lumbar puncture, she was imme- 
diately removed from that large group of functional conditions, and when 
it was not relieved by the usual medical treatment, then it had to be treated 
mechanically — that is, the operation of subtemporal decompression. 

Case 125. — Chronic severe brain injury with a resulting cortical and 
supracortical hemorrhagic cyst formation directly beneath the site of the 
bullet-injury of the vault; no fracture of the skull. Mental retardation, 
emotional instability and Jacksonian convulsive seizures. No operation. 
Death from opium poisoning. Autopsy. 

No. 014. — Ling. Thirty-four years. Yellow. Married. Clerk. China. 

Admitted April 10, 1912 — 6 years after gunshot injury. St. Luke's 
Hospital, Shanghai. Referred by Doctor A. W. Tucker. 

Died April 11, 1912 — 20 hours after admission. 

Family history negative ; both parents and the relatives were right- 
handed (as well as could be ascertained by questioning the relatives present) . 
Patient has always been left-handed. 

Personal History. — Always well and strong with the exception of the 
usual diseases of childhood. During the six years preceding the cranial 
injury, the patient worked as a clerk in the British-American Tobacco 
Company, where he was considered an unusually capable and intelligent 
employee. Seven years ago (November 6, 1905), the patient was shot in a 
Boxer uprising in the right temple ; only momentary loss of consciousness ; 
patient was able to walk to his home, and with the exception of a dull head- 
ache there were no complaints ; the small scalp wound of bullet entrance was 
bandaged and the wound healed without the formation of pus. (At the 
time, it was not thought that a foreign body had entered the scalp wound.) 
Patient was able to return to his office work upon the following day, but on 
account of continuous severe headache and an inability to perform his work 
properly, he was obliged to give up his position after a period of ten days. 
He gradually became restless, irritable, unable to sleep well and complained 
of severe headache for a period of several months; no speech impairment, 
however, was observed at any time. The patient no longer appeared inter- 
ested in things and would sit by himself for hours at a time, holding his 
head in both hands ; if disturbed, he would become enraged, and on two 
occasions he assaulted his annoyers. Five months after the cranial injury, 
the first convulsive seizure occurred — beginning on the left side of the 
face, then the left arm, later the left leg and finally the entire body — and 
it lasted for over five minutes ; apparently an entire loss of consciousness 
was present. During the past six years, the condition has gradually pro- 
gressed in that the convulsive seizures (which always begin on the left side) 
have increased in frequency so that during the past three months, they 
have occurred as many times as six in one week ; very irritable and excitable, 
and then, at times, very much depressed — crying for hours at a time on 
account of "pain in head"; no longer remembers the simplest things. Two 



CHRONIC BRAIN INJURIES 493 

months ago he drank a large amount of liquid opium with suicidal intent, 
but the vomiting was so profuse that he recovered ; he stated at that time 
that he would attempt it again later. 

Present Illness. — Thirteen hours before admission to the hospital, the 
patient swallowed a large quantity of liquid opium — he was profoundly 
unconscious ; brought to the hospital upon a stretcher. 

Examination upon admission (7 years after cranial gunshot injury 
and 13 hours after drinking the opium). — Temperature, 97° ; pulse, 18 and 
very irregular ; respiration, 6, and very shallow and irregular. Profoundly 
unconscious ; cold, clammy skin. At times, the pulse and respiration prac- 
tically cease — requiring artificial respiration. Both pupils are of pin-point 
size and non-reactive to light. Reflexes — both superficial and deep are all 



Fig. 146. — Small fragments of leaden bullet imbedded in the posterior portion of the right half of 
the frontal bone just anterior to the coronal suture. The outer table of the underlying bone was merely- 
indented but very slightly. The attachment of the right temporal muscle to the parietal crest is 
well portrayed. 

abolished. During the examination, a brother told the interpreter about 
the former gunshot injury, and upon careful palpation it was possible to 
feel a small foreign body directly beneath the old scar over the posterior 
portion of the right half of the frontal bone. 

Treatment. — The usual emergency treatment for these patients — artificial 
respiration, vigorous massage and passive exercises, heated blankets and hot 
water bottles, repeated gastric lavage and high colonic irrigation, hypo- 
dermic injections of caffeine, etc. The condition of the patient, however, 
rapidly became worse in that the pulse and respiration became more and more 
irregular and also weaker, the pupils gradually dilated (permitting a careful 
ophthalmoscopic examination to be made) and the patient died 16 hours 
after admission and 29 hours after the ingestion of the opium. The fundi 
presented the appearance of a mild secondary optic atrophy with irregular 
nasal margins obscured by edema. 

Autopsy of head alone: directly beneath the scar of the scalp from the 



494 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

former head injury in the right posterior frontal area, was a leaden bullet 
(fragmented) indenting slightly the outer table of the underlying bone (Fig. 
146). No fracture of the bone could be found and no depression of the 
inner table of the vault was ascertained. The dura beneath this point of 
contact was definitely thickened over an area of 2 inches in diameter, and 
lying directly under it and connected with it by numerous adhesions was 
an oval supracortical and cortical hemorrhagic cystic formation of 3 cm. 
in diameter ; it extended into the cortex to a depth of 2 cm. and occupied 
the posterior portion of the right second and third frontal convolutions — 
just anterior to the right fissure of Sylvius (Fig. 147) ; upon incising its 
outer wall, a straw-colored fluid escaped, permitting the cyst to collapse. 
The supracortical vessels adjacent to this cyst formation were indurated and 




Fig. 147. — Dark hemorrhagic cyst in the posterior portion of the right frontal lobe and directly beneath 
the gun-shot injury of the vault — and no fracture of the bone present. 

surrounded in the sulci by a cloudy thickening of connective tissue — the end- 
result of a former supracortical hemorrhage. The edematous cerebral 
cortex, other than that of the right frontal and the contiguous areas' of the 
right temporo-sphenoidal lobes, was normal; no cortical adhesions found 
elsewhere. Ventricles were negative. 

Remarks. — There can be no question that the cerebral injury occurring 
in this patient in good health was the primary cause of the increased intra- 
cranial pressure producing the headache and the mild secondary optic 
atrophy, and the later development of the mental and emotional impairment 
and the Jacksonian epilepsy. If a careful neurological examination had 
been possible within a short time after the injury, it is possible that this 
patient could have been permanently relieved and benefited by a right 
subtemporal decompression and drainage of the supracortical and cortical 
hemorrhage; at least, the increased intracranial pressure could have been 
lowered and thus the headache avoided and the impairment of vision pre- 



CHRONIC BRAIN INJURIES 49* 

vented — as well as lessening the danger of the later mental and emotional 
impairment and the convulsive seizures. It is most doubtful if a marked 
improvement could have been obtained after the cortical irritability had 
been so increased that the convulsive seizures were occurring in such great 
frequency — the so-called epileptic habit; it would, however, have been 
advisable to perform the operation even at this late date in the hope that 
an improvement was possible — at least a retardation of the progress of 
the deterioration. 

The absence of a fracture of the vault of the skull in this patient is 
interesting. The situation of the hemorrhagic cyst in the second and third 
right frontal convolutions posteriorly in a left-handed patient and yet 
no motor impairment of speech is most suggestive ; the fact that his rela- 
tives and ancestors were all right-handed and therefore their motor speech 
centers were presumably in the cerebral cortex of the left frontal lobe, 
and that in this left-handed patient a destruction of his theoretical motor 
speech centre in the cortex of the right frontal lobe did not produce a 
speech impairment, would tend to indicate that in this patient at least, the 
motor speech area of the cerebral cortex is situated in either cerebral 
hemisphere more as the result of one's ancestry and heredity rather than 
as influenced by the individual himself, whether right-handed or left- 
handed ; in this patient naturally, one would expect the motor speech area 
to be in the right cerebral cortex — the patient himself being left-handed, 
but the pathology as disclosed by the autopsy would tend to confirm the 
belief that in this patient, at least, the motor speech area was in the usual 
posterior portion of the left third frontal convolution (Broca 's area) . 

F. Chronic Brain Injuries Complicated by Other Conditions 

Among the more common complications occurring in the patients hav- 
ing chronic brain injuries are cardio-vascular and carclio-renal diseases, with 
and without the factor of alcoholism ; brain tumors which frequently appear 
beneath and at the site of the former cranial and cerebral lesion ; the various 
manifestations of lues, and especially of the cerebrospinal type and of 
paresis itself; mental derangements, and particularly the frank forms of 
traumatic dementia and the other types of mental disease which occa- 
sionally follow severe brain injuries, as though the intracranial lesion 
had at least precipitated the mental impairment; it is only in the ex- 
ceptional patient that the history of the cranial trauma is the direct cause 
for the permanent mental derangement ; the cerebral lesion may be a 
predisposing cause but rarely, if ever, the sole factor in the condition of 
frank manic-depressive insanity, dementia precox and even of traumatic 
dementia itself. 

A. Nephritis. 

Case 126. — Chronic severe brain injury associated with a linear fracture 
of the vault, high intracranial pressure and with nephritis. Eight subtem- 
poral decompression; improvement. Spontaneous hemorrhage later into 
left ventricle ; death. Autopsy. 

No. 583. — William. TAventy-seven years. White. Single. Electrician. 
United States. 



496 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Admitted May 25, 1916 — 7 months after injury. Polyclinic Hospital. 
Referred by Doctor J. F. White. 

Operation June 12, 1916 — 17 days after admission. Right subtem- 
poral decompression. 

Died September 4, 1916 — 11 months after injury and 82 days 
after operation. 

Family history negative. 

Personal History. — Perfectly well until 9 months ago (2 months before 
injury), when patient had severe headaches each morning upon arising and 
lasting over 2 hours; no frequency of urination and no medical attention 
was requested. Seven months ago while at work, patient was struck upon 
the head by a large iron bolt ; no loss of consciousness ; watery fluid, how- 
ever, escaped from the right ear and continued for 3 days after the injury, 
when the headache again returned. Patient continued working during the 
following month until the general headache became so severe that he was 
obliged to remain in bed; no other complaint except persistent and con- 
tinuous headache. Repeated urine examinations revealed much albumen 
and many hyaline and granular casts. 

Examination upon admission (7 months after injury). — Temperature, 
98.8° ; pulse, 82; respiration, 26; blood-pressure, 200. Well-developed and 
nourished. Perfectly conscious but rather drowsy and complaining of severe 
frontal headache. Impairment of hearing of right ear — bone conduction 
being greater than air conduction; otoscopic examination reveals a small 
irregular perforation in the posterior half of right tympanic membrane. 
Pupils equal and react normally. Reflexes — patellar very much exaggerated 
— right more than left; right ankle clonus inexhaustible — left exaustible; 
right Babinski and plantar flexion not obtained on the left foot ; abdominal 
reflexes — right absent. Fundi (Doctor J. A. Kearney) — "regenerative 
choked disks ; entire outline of left disk was obliterated, although no tissue 
elevation; right — no degeneration noticed but disk outlines are obscured 
in old exudate. Both fundi are congested and suffused; retinal veins en- 
larged. ' ' Lumbar puncture — clear cerebrospinal fluid under high pressure 
(approximately 22 mm.) ; Wassermann test negative and cell count was 4 
cells per c.mm. X-ray (Doctor W. H. Stewart) — "small linear fracture 
extending obliquely through the lower posterior part of the right parietal 
bone toward right frontal area" (Fig. 148). Urine examination (Doctor 
W. L. McFarland) — "heavy trace of albumen; numerous hyaline and 
finely granular casts." 

Treatment. — Vigorous medical treatment was administered by Doctors 
Wightman and Bishop in the hope that the increased intracranial pressure, 
due to the cerebral edema associated with nephritis in a patient having the 
history of the cranial injury, could be lessened and thus the vision be 
spared. Within 2 weeks after admission, the condition steadily progressed 
so that the blood-pressure became 240, the ophthalmoscope revealed ' ' choked 
disks" of 5 diopters and a lumbar puncture registered the pressure of the 
cerebrospinal fluid as being approximately 28 mm. ; patient became more 
and more stuporous, so that it was now considered advisable to perform 
a right subtemporal decompression to lower the increased intracranial pres- 



CHRONIC BRAIN INJURIES 



497 



sure mechanically and thus, at least, save the eyesight and permit the 
patient to withstand the nephritis much better than when subjected to this 
high intracranial pressure. 

Operation (17 days after admission). — Right subtemporal decompres- 
sion: usual vertical incision, bone removed, and no complications; much 
bleeding occurred, however, due to the high blood-pressure. Dura exceed- 
ingly tense, and upon incising it, a large quantity of cerebrospinal fluid 
escaped in gushes as though walled off by adhesions ; the underlying ' ' wet, ' ' 
edematous cortex protruded but did not rupture, and owing to the rapid 
escape of much cerebrospinal fluid, the brain pulsated at the end of the 
operation. No cortical hemorrhages or lacerations visible — merely a very 
''wet" brain under high pressure. Usual closure with 2 drains of rubber 
tissue inserted. Duration, 
55 minutes. 

Post-operative Notes. — 
Patient made an excellent 
operative recovery so that at 
the end of 22 days he 
was sent home under medi- 
cal treatment. 

Examination at d i s- 
charge (22 days after oper- 
ation) . — T emperature, 
98.6° ; pulse, 80 ; respiration, 
24; blood-pressure, 178. No 
complaints except slight dull 
headache in the morning. 
Decompression area bulges 
slightly and pulsates nor- 
mally. Pupils equal and 
react normally. Reflexes — 
patellar exaggerated but 
equal ; double exhaustible 
ankle clonus but suggestive 

right Babinski ; abdominal reflexes present and equal. Fundi — retinal veins 
enlarged ; both, fundi congested and suffused but only nasal halves of optic 
disks blurred by edema; both physiological cups shallow and filled with 
new tissue and the margins of optic disks rather irregular. Urine examina- 
tion — heavy trace of albumen and numerous hyaline and finely granu- 
lar casts. 

Treatment. — Patient was carefully instructed regarding his medical 
treatment, diet, etc., and was advised to return each week to the out-door 
medical clinic for observation. 

Examination (August 22, 1916 — 48 days after discharge). — Patient 
returned to the hospital for the first time and complained of intense 
frontal headaches, nausea and frequent vomiting — the symptoms and signs 
of the toxemia of nephritis. Temperature, 99°; pulse. 88; respira- 
tion, 26 ; blood-pressure, 204. Decompression area bulging tensely. Pupils 
32 




Fig. 148. — Small linear fracture of right parietal bone in a 
patient having chronic nephritis and a high intracranial 
pressure producing a secondary optic atrophy. Death due to 
later spontaneous hemorrhage into left ventricle. 



4 q8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

equal and react normally. Reflexes — patellar very active but equal ; double 
ankle clonus and double suggestive Babinski; abdominal reflexes obtained 
with difficulty. Fundi — double "choked disks" of 6 diopters; retinal veins 
dilated and buried in the edematous tissue of retinas. Urine exmaination — 
large amount of albumen and many hyaline and granular casts. 

Treatment. — Patient was admitted to the ward and the most vigorous 
medical treatment administered, so that within one week patient was 
apparently in much better general physical condition and the headaches had 
almost entirely disappeared. A rontgenogram was negative except for the 
bony defect of the decompression opening; three silver clips are shown. 
On August 29 (7 days after admission), when patient seemed to be making* 
an excellent recovery, a left hemiplegia suddenly occurred and the follow- 
ing examination was made: Temperature, 99° ; pulse, 104; respiration, 30; 
blood-pressure, 230. Profoundly unconscious and in state of collapse. De- 
compression area was ' ' tight as a drum ' ' and no pulsation palpable. Pupils 
— left dilated and does not react to light. Reflexes — patellar exaggerated, 
left being greater than right; double ankle clonus and double Babinski; 
abdominal reflexes — left absent, right depressed. Fundi — retinal veins 
dilated; "choked disks" of 6 diopters. Lumbar puncture — clear cerebro- 
spinal fluid under exceedingly high pressure (approximately 30 mm.). 
Urine examination — large amount of albumen and many hyaline granu- 
lar casts. 

Treatment. — In spite of vigorous medical treatment, the condition of 
patient rapidly became worse, so that 12 houra after the hemiplegic attack 
the temperature ascended to 106°, pulse to 160 plus, and respiration to 
48, while the blood-pressure now descended to 116; pulmonary edema 
appeared and patient died — 16 hours after hemiplegic attack and 82 days 
after operation. 

Autopsy (Doctor T. D. Lehane) : over the posterior portion of right 
parietal area was a small depressed fracture of the outer table of the vault 
alone ; one inch below this area was a linear fracture extending obliquely 
forward into right frontal bone ; small fracture of right petrous bone. No 
subdural hemorrhage present. In the left lateral ventricle was a tense hemor- 
rhagic clot, the size of a lemon, and thus compressing directly the left pyra- 
midal tract fibres. Right lateral ventricle negative. Brain itself was very 
edematous and swollen. Subtentorial region negative. 

Remarks. — Having thus been enabled to trace this patient from almost 
the beginning of his condition to the end, we are in a position to estimate 
the various factors complicating the condition, and it would appear that a 
chronic nephritis was the underlying cause of the intracranial condition 
which was precipitated by the cranial injury; that is, the cranial injury 
caused an acute cerebral edema to occur chiefly on account of the presence of 
the chronic nephritis, and there may have been already a mild cerebral edema 
even at the time of the cranial injury and due to the chronic nephritis 
alone — the presence of headache for the two months preceding the cranial 
injury might indicate this. 

It is interesting to observe the immediate improvement of the patient's 
condition and particularly the lessening of the intracranial pressure as the 



CHRONIC BRAIN INJURIES 499 

result of the subtemporal decompression ; naturally, it was advised only as 
an immediate means of sparing the vision and to enable the patient to 
resist a nephritis more effectively; it was the first patient that I had ever 
advised the operation of subtemporal decompression to lessen an increased 
intracranial pressure primarily due to a chronic nephritis, even though 
complicated by a cranial injury, and it was only advised after all medical 
treatment had failed to retard the progress of the condition. The tem- 
porary improvement following the operation was most encouraging. 

The- sudden left hemiplegia and the autopsy findings of a large left 
ventricular hemorrhage are difficult to correlate ; anatomically, it would seem 
that the left pyramidal tract fibres should have been more compressed than 
the right pyramidal fibres, and I am at a loss to explain it satisfactorily — 
unless the indirect pressure of a clot in the left hemisphere could exert a 
greater compressive effect on the pyramidal tract fibres of the right 
hemisphere than upon those of the left hemisphere — and this does not seem 
logical. Careful examination of the right hemisphere and the right pyra- 
midal tract fibres down through the internal capsule did not reveal any lesion. 

It is interesting to note in the history that the patient had had severe 
headache during the two months preceding the injury and then, in spite 
of the cranial injury sufficient to cause a fracture of the skull, this patient 
did not complain of headache during the 3 days following the injury and 
while cerebrospinal fluid was escaping through the line of fracture out of 
the right ear; that is, this discharge of cerebrospinal fluid so lessened the 
increased intracranial pressure of the chronic cerebral edema due to the 
pre-existing nephritis, that the headache disappeared and only returned 
when the cessation of the flow of cerebrospinal fluid from the ear occurred — 
3 days after the cranial injury. This is an excellent illustration of "natural 
decompression" afforded the patient by the fracture of the skull; fortu- 
nately, no infection through this line of fracture into the ear occurred — 
the longer the aural discharge persists, the greater the danger of infection 
and a resulting meningitis. 

The presence of the ' ' regenerative choked disks ' ' indicates an increased 
intracranial pressure of long duration, and in this patient its mild secondary 
optic atrophy was exhibited and therefore a permanent impairment of the 
vision of mild degree would result. 

Following the sudden left hemiplegia with extreme intracranial pres- 
sure, the right decompression area and right ventricle might naturally have 
been explored with negative results. 

B. Tumor of the brain. 

Case 126a. — Old cranial injury associated with mild signs of an in- 
creased intracranial pressure; osteo-sarcoma of left squamous bone; sub- 
cortical cerebral sarcoma. Operation. Improved. 

No. 260. — Linley. Twenty-nine years. White. Married. Physician. U. S. 

Admitted May 26, 1915 — 5 years after second injury. Polyclinic Hos- 
pital. Referred by Doctor C. C. Sweet, 

First operation July 13, 1915 — 47 days after admission. Left subtem- 
poral decompression and partial craniectomy. 

Discharged August 2-4, 1915 — 41 days after operation. 



5 oo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Second operation March 12. 1916 — S months after first operation. Left 
exploratory osteoplastic operation. 

Discharged April 6. 1916 — 21 days after operation. 

Family history negative. 

Personal History. — Patient was an only child, full term, normal delivery 
and considered a normal boy ; usual childhood diseases. When one year 
of age. patient fell from a chair, striking the left side of head against the 
leg of the table ; unconscious for 15 minutes ; several drops of blood trickled 
from left external auditory canal : after 10 days in bed. the condition was 
excellent and the injury was forgotten. As a boy. patient had severe frontal 
headaches twice each month. In 1910 5 years before admission;, patient 
fell from a motor-cycle, striking the left side of head : no loss of consciousness 
but dazed for a number of minutes. Patient considered himself perfectly 
well until February. 1911 1 years ago), when he suddenly became aware 
of a numbness beginning in the right hand and extending over the entire 
right half of the body — a '"sensory convulsion" and no motor signs: this 
attack lasted one minute, and then the sensation became normal. The>e 
sensory spells occurred daily several times — always beginning in the right 
hand and limited entirely to the right side of the body — and they have 
continued up to the present time: during 1913. there was an interval of 3 
months during which time no sensory spells occurred. In January. 1911 
1 17 months before admission . patient had his first Jacksonian convulsive 
seizure : following the sensory spell, the fingers of the right hand twitched. 
then the entire right arm. and finally the entire right half of the body — and 
no loss of consciousness ; each spell lasted from 2 to 3 minutes. On May 1. 
1911 (12 months ago), patient had his first convulsive seizure associated 
with loss of consciousness ; the attack began as usual in a numbness of the 
right side of the body, then a motor convulsion of the right arm and then 
the right side of face and right leg. which now became a general convulsion 
when the patient lost consciousness ; this attack lasted 15 minutes and he dislo- 
cated both arms at the shoulder during it. These major seizures of this 
character and type have continued every few days, while the minor attacks 
of numbness of the right side of the body and slight Jacksonian seizures 
limited to the right arm have been daily, and frequently several times each 
day. During this period, patient has had severe frontal and occipital head- 
aches lasting 21 hours at a time. During past year he has been obliged 
to wear hats three sizes larger than before. 

Present Illness. — Patient now comes to the hospital complaining not only 
of the numbness of the right side of the body, which is always present, 
and of the daily Jacksonian convulsions and of the frequent general con- 
vulsions, but a definite motor aphasia incomplete and paraphasia have 
occurred associated with an inability to '"concentrate my mind" and a dis- 
tinct loss of memory, especially for recent events. 

Examination upon admission f years after injury' . — Temperature. 98.8 = ; 
pulse. SO : respiration. 21 ; blood-pressure. 131. A fair development and 
nourishment. Perfectly rational and conscious, but a distinct hesitancy in 
speech and a difficulty in using proper words ; no sensory aphasia. No exter- 
nal evidence of cranial lesion. Hearing: negative : taste and smell negative. 



CHRONIC BRAIN INJURIES 501 

No nystagmus. Romberg test negative. Pupils equal and react to light nor- 
mally. Reflexes — patellar active, right more than left; right exhaustible 
ankle clonus and tendency to right Babinski ; abdominal reflexes — right de- 
pressed. Fundi — retinal veins enlarged ; upper and lower nasal quadrants 
of both optic disks slightly blurred — left possibly more than right ; physio- 
logical cups rather shallow, but no ' ' choked disks ' J nor measurable swelling 
of the disks. Lumbar puncture — clear cerebrospinal fluid under slightly 
increased pressure (approximately 13 mm.) ; Wassermann test negative and 
cell count was 5 per c.mm. X-ray (Doctor A. J. Quimby) — "an irregular 
line of fracture extending horizontally through the left squamous bone back- 
ward to the left occipital bone ; in this area there is a definite blur, possibly 
of thickened bone. ' ' Urine examination negative. Definite weakness of the 
right arm, but no weakness of right leg or right side of face can be elicited. 
Careful sensory tests of right side of the body reveal no sensory impairment 
to light-touch, pain, or temperature ; no astereognosis nor apraxia. 

Treatment.- — After studying this patient and examining him frequently 
during a period of 45 days in which a number of major convulsions were 
accurately reported, it was finally decided that a left subtemporal decom- 
pression and exploration should be performed. (Owing to the fact that 
this patient had been repeatedly assured that his condition was due to intes- 
tinal stasis and the operation of colectomy advised as a remedy for his ills, 
it was with great difficulty that the patient could be convinced that there 
was a definite local lesion underlying the left side of his skull which was the 
possible cause of his condition.) 

First Operation (47 days after admission). — Left subtemporal decom- 
pression, exploration and removal of tumor of bone : usual vertical incision, 
bone removed, and no complications; extending transversely through the 
lower portion of the left squamous bone was an irregular line of an old 
fracture ; the bone was 2 cm. in thickness and very hard, extending inward 
and depressing the underlying dura; this thickened area of bone formed 
an irregular prominence of 2 inches in width ; it was entirely removed. The 
underlying dura was thickened, whitish and tense, and upon incising it, a 
very edematous "wet" swollen cortex tended to protrude but did not 
rupture ; upon the cortex, especially in the sulci and about the cortical veins, 
there was a hazy whitish induration — the result of a former subarachnoid 
hemorrhage at the time of the cranial injury. It was considered that 
sufficient cause extradurally had been found to account for the patient's 
symptoms and signs, and as the operation had already lasted 90 minutes 
and the patient not being in good condition due to much pulmonary mucus 
resulting from the ether, and on account of the loss of much blood due to the 
removal of a large area of thickened bone, it was, therefore, decided not to 
explore the brain itself. Usual closure with 2 drains of rubber tissue inserted. 

Post-operative Notes. — Patient had a very stormy convalescence ; the 
bronchitis following operation developed into a right pneumonia and then 
pleurisy, but after these complications the patient made an excellent recovery 
eventually and was able to leave the hospital 41 days after operation. 

Examination at discharge (41 days after operation ), — Temperature. 
98.6°; pulse, 82; respiration, 24; blood-pressure, 130. No complaints of 



5Q2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



headache and patient has not had a minor spell or major seizure since the 
operation. Slight weakness of right arm persists but no impairment of sen- 
sation can be elicited, Decompression area bulges slightly beyond flush of 
scalp ; pulsation normal. Pupils equal and react normally. Reflexes — patel- 
lar active, right possibly more than left ; no ankle clonus and no Babinski ; 
abdominal reflexes — right less active than left. Fundi — retinal veins 
slightly enlarged ; nasal margins of both optic disks indistinct but other 
details of optic disks clear. A second X-ray disclosed the left decompression 
opening, the posterior portion of the line of fracture and three silver 
clips in situ (Fig. 149). 

After the patient returned home, the first minor spell (entirely sensory in 
character) occurred 13 weeks after operation and continued at irregular 
intervals of 2 to 3 times a week. The first major seizure occurred on October 

15, 1915—92 days after op- 
,— i •"•* eration; the second major 

seizure following operation 
occurred 3 weeks later, and 
then both minor spells and 
major seizures reappeared 
with increasing frequency 
until the patient returned to 
the hospital in March, 1916. 
Examination upon sec- 
ond admission (8 months 
after first operation) . — Tem- 
perature, 98.6°; pulse, 70; 
respiration, 18; blood-press- 
(B^HESHHI ure < 140- Conscious. Decom- 

pression area flush with sur- 
rounding scalp ; normal pul- 
sation. Increasing difficulty 
of speech — chiefly a para- 
phasia ; no sensory aphasia. 
Unable to recall recent events. Complains of continuous numbness of right 
side of body; no sensory impairment can be elicited and no astereognosis 
nor apraxia. No impairment of taste, smell or hearing. No dreamy states 
of unreality nor temporo-sphenoidal "fits." No limitation of the visual 
fields and no hemianopsia. Pupils equal and react normally. Reflexes — 
patellar exaggerated, right more than left ; double exhaustible ankle clonus 
and suggestive right Babinski ; abdominal reflexes — right depressed. Fundi : 
retinal veins enlarged; slight blurring of nasal margins of both optic 
disks. Definite weakness of entire right side of body, however — arm more 
than leg; right facial weakness of cortical type (right forehead muscles 
not involved). No impairment of sensation can be elicited to light-touch, 
pain or to temperature. 

Treatment. — As the condition had only been temporarily improved by 
the last operation and as the neurological examination still indicated a 




Fig. 149. — Oval bony defect of left subtemporal decompres- 
sion in a patient having convulsive seizures following an old 
fracture of the left vault, and associated with an increased 
intracranial pressure ; marked improvement following its oper- 
ative lowering and removal of osteo-sarcoma of left squa- 
mous bone. 



CHRONIC BRAIN INJURIES 503 

lesion of the left hemisphere, it was considered advisable to perform a left 
osteoplastic flap operation and exploration of the left hemisphere. 

Second Operation (8 months after first operation). — Left exploratory 
osteoplastic operation: usual curvilinear incision over left lower parietal 
area; bone-flap "turned down" and no complications. Dura incised in 
curvilinear manner ; underlying cortex tense and in sulci about the vessels 
was a whitish cloudy induration due to the former subarachnoid hemor- 
rhage at time of cranial injury. Upon attempting to tap the ventricle with 
a puncture needle, a rather resistant mass was encountered 3 cm. beneath 
the cortex and underlying the lower portion of left Rolandic area; this 
tumor mass was apparently the size of an orange. (Small specimen removed 
for examination was reported by Doctor Jeffries as being ' ' small-celled sar- 
coma.") It was considered better surgical judgment not to attempt a 
removal of this tumor on account of its position beneath the left motor 
cortex and thus a more or less complete paralysis of the right side of the 
body would have resulted from its operative removal, and also the fact 
that it was of soft consistency and therefore undoubtedly malignant, and 
thus a recurrence would be most liable even if the tumor could now be 
surgically removed; again, it was hoped that the tumor might extrude 
itself gradually through the upper portion of the temporal lobe toward 
the site of decompression and thus its removal might be effected with very 
little damage (particularly is this so with spinal cord tumors of the medullary 
type). Usual closure and bone-flap replaced. Duration, 85 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery and 
he was discharged 24 days after operation. 

During the past 30 months, I have repeatedly examined this patient. 
Much to our surprise, this patient was able to return to his work, which he 
continued for 9 months after operation ; then on account of an occasional 
major seizure, patient accepted an out-door position and was able to work 
until 4 months ago, when on account of increasing aphasia and the fre- 
quency of both minor spells and major seizures, the patient has been 
living quietly at home. 

Last Examination (November 29, 1909 — 54 months after first operation 
and 44 months after second operation). — Patient complains of persistent 
numbness of right side of body, particularly right arm, weakness of right 
arm and frequent minor spells and major seizures always beginning on right 
side of body. No headache and no impairment of vision. No impairment 
of taste, smell or hearing. Decompression area bulges under tension ; upon 
performing lumbar puncture, this protrusion disappeared entirely when 2 
ounces of cerebrospinal fluid were removed. Pupils equal and react nor- 
mally. Reflexes — patellar active, right more than left; exhaustible right 
ankle clonus but no Babinski ; abdominal reflexes — right less active than left. 
Fundi — nasal margins of both optic disks clear ; retinal veins enlarged. No 
objective sensory impairment of right side of body, and no astereognosis 
and no apraxia. Definite weakness of right arm and less so of right leg 
and right side of face. Upon removing cerebrospinal fluid at lumbar 
puncture, patient experienced a marked improvement during the following 
6 weeks in that no major seizures occurred and his general condition im- 



5o 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

proved in every way. As a result of this observation, a lumbar puncture and 
withdrawal of 2 ounces of cerebrospinal fluid is now being performed 
each week. 

Be marks. — This is a most instructive case in that it would seem that 
a sarcoma of the vault had occurred years following a fracture of the skull 
in that area ; the definite symptoms and signs indicating a lesion of the left 
hemisphere were, at operation, considered as being due to the tumor of the 
bony vault alone, and naturally the underlying cerebral cortex and subcortex 
were not explored, merely a left subtemporal decompression being per- 
formed; later, when the patient's symptoms and signs persisted, a second 
operation was performed and a subcortical sarcoma, the size of an orange, 
located ; owing to its position and undoubted malignancy, its operative 
removal was not attempted in the hope that it might extrude itself toward 
the decompression opening. At the last examination, when the patient 
entered the hospital having a hernial protrusion at the site of the decom- 
pression opening, it was hoped that this extrusion of the tumor had indeed 
occurred, but upon removing the cerebrospinal fluid at lumbar puncture 
this protrusion disappeared entirely and thus it may be considered as 
being due merely to blocked cerebrospinal fluid. The patient's condition 
during the past 6 months has been steadily becoming worse, and it is only 
since the repeated withdrawal of cerebrospinal fluid at lumbar punctures 
that a marked improvement in this condition has occurred; undoubtedly, 
these improvements, however, are only temporary. 

It was hoped at the time of the second operation that, if the tumor did 
not extrude that it might degenerate by the formation of cysts, similarly 
to the frequent cystic degeneration of gliomata and thus the malignancy 
of the tumor be lessened and that possibly an ultimate recovery might occur ; 
this fortunate result is indeed of rare occurrence, but it is possible, although 
the usual length of life following the existence of cerebral tumors of malig- 
nant character is on the average only 3 years. It was most important in this 
case, as in all patients having brain tumors, that a decompression should 
be performed early, no matter whether the tumor is malignant or not; 
in this way. the headaches are lessened, the vision is spared and a fairly 
comfortable existence is assured to the patient ; besides, if the tumor is 
not malignant, then its early localization and removal is possible, and yet 
the vision of the patient is spared, and if the tumor should be malignant then 
the patient can be assured a fairly comfortable existence for several years, 
and yet the patient be not blind and a pitiful sufferer from the severe con- 
tinuous headache. There is also, fortunately, the possibility that the diag- 
nosis of malignancy of the tumor is a mistaken one — and this mistake does 
occasionally occur and possibly more frequently in the diagnosis of tumors 
of the brain, so that, the increased intradural pressure having been re- 
lieved by the decompression and if necessary a bilateral decompression, 
then the patient may be able to lead a fairly comfortable life, if not to regain 
his former mental and physical activity ; the vision will at least have been 
spared, the headaches stopped and in every way a marked improvement 
obtained — even if only a temporary one of several years. 

Case 127. — Old severe brain injury associated with an increased intra- 



CHRONIC BRAIN INJURIES 505 

cranial pressure and later with convulsions. Right osteoplastic exploration ; 
improvement. Emotional changes later associated with increasing intra- 
cranial pressure. Left subtemporal decompression and exploration ; supra- 
cortical angiomatous plexus formation. Improvement. 

No. 829. — Stephen. Twenty-three years. White. Single. Student. U. S. 

Admitted March 22, 1917 — 15 years after injury. Johnson- Willis Hos- 
pital, Richmond, Va. Referred by Doctor Beverly R. Tucker. 

Operation April 4, 1917. — Left subtemporal decompression, exploration 
and drainage. 

Discharged April 30, 1917 — 16 days after operation. 

Family history negative. 

Personal History. — Full term baby, difficult labor and no abnormalities 
observed immediately after birth. Usual childhood diseases. Patient was 
considered a normal boy until he was 8 years of age, when he began to have 
severe headaches and occasional " dizzy" spells and 12 years ago (when 
patient was 11 years of age), severe epileptiform convulsions occurred and 
of such frequency that the condition became one of status epilepticus — 
general convulsions with loss of consciousness and an attack occurring every 
20 minutes. Patient was taken to the Johns Hopkins Hospital, where Doc- 
tor Harvey Cushing performed a right osteoplastic exploration and relief of 
the high intracranial pressure ; a very ' ' wet, ' ' edematous cortex under high 
tension was revealed ; no other abnormality noted. Patient made an excel- 
lent operative recovery — quickly regained consciousness, convulsions sub- 
sided and did not recur. Markedly improved for one year, when slight dull 
headaches and occasional ' ' dizzy ' ' spells reappeared, but never so severe as 
before the operation. It was now noticed, however, that the patient was 
changing emotionally in that he became less affectionate than before, and 
would lie needlessly, showing a marked tendency to steal and to burn articles 
both of value and then again trifles. In the meantime, the patient had 
progressed through the various elementary and secondary schools and finally 
reached college, where he was considered a normal boy, although rather ' ' ec- 
centric. " Patient had periods of "wanderlust," when he would make trips 
to no purpose — merely because he was restless and could not remain quiet. 
The desire to burn and steal larger things increased and he finally yielded to 
a frequent temptation by burning a large building and stealing numerous 
articles — some of value, others not ; this last offence occurred 4 months 
before admission to the hospital. 

Examination (in consultation with Doctors Tucker and Willis, April 
6, 1917). — Temperature, 98.2°; pulse, 66; respiration, 18; blood-pressure. 
132. Well-developed and nourished. Perfectly conscious but reticent and 
apparently cynical; emotional reactions depressed and upon superficial 
examination, the condition might have been considered an early case of 
dementia praecox; patient was apparently oblivious to his surroundings, 
not affectionate to his relatives and he did not seem to realize the notoriety 
and the humiliation of his family due to the immensity of his crime — 
there being a criminal charge against him. Area of the former left osteo- 
plastic operation was negative. No impairment of taste, smell or hearing. 



506 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Pupils equal aud react normally. Reflexes— patellar very active, right 
greater than left; no ankle clonus but suggestive right Babinski; abdominal 
reflexes— right depressed. Fundi— retinal veins enlarged; nasal margins 
of both optic disks blurred and lower nasal quadrant of left optic disk°ob- 
scured by edema. Lumbar puncture— clear cerebrospinal fluid under in- 
creased pressure (approximately 16 mm.) ; Wassermann test negative and 
cell count Avas 8 cells per c.mm. X-ray (Doctor A. L. Gray)— "convolu- 
tional pressure markings upon the inner tables of the vault over the frontal 
area; new bone formation about the periphery of the former exploratory 
operation." No weakness of arms or legs; no sensory impairment; no 
aphasia or astereognosis. 

Treatment. — On account of the increased intracranial pressure and the 




Fig. 149a. — The normal appearance of the cere- 
bral cortex in the area exposed by the operation of 
left subtemporal decompression 



Fig. 1496. — Angiomatous plexus of enlarged supra- 
cortical veins associated with a high intracranial 
pressure, as disclosed by the left subtemporal de- 
compression upon this patient. 



localizing signs of a greater involvement of the left hemisphere, a left 
subtemporal decompression and exploration was advised in the belief that 
a lowering of this increased intracranial pressure would lessen the emo- 
tional instability of the patient by diminishing the cortical irritability 
and thereby cause an improvement, and also diminish the danger of the 
occurrence of future convulsions ; in brief, the operation was advised in 
the hope that it might give the patient a definite chance of recovery by 
lowering the increased intracranial pressure. 

Operation (15 years after injury) . — Left subtemporal decompression and 
exploration : usual vertical incision of 3% inches in length extending from 
the left parietal crest down to the left zygomatic arch — y 2 inch anterior to 
the left external auditory meatus. Skin flaps retracted and the temporal 
fascia and muscle were now incised similarly in the direction of the mus- 
cular fibres; these were retracted, exposing the underlying squamous por- 



CHRONIC BRAIN INJURIES 507 

tion of the temporal bone and the lower portion of the left parietal bone, 
which were now opened and rongeured away to a diameter of 2y 2 to 3 inches, 
revealing a tense thickened fibrous dura, non-transparent and under high 
tension, so that it tended to protrude. Upon making a small opening in the 
dura, clear cerebrospinal fluid spurted a distance of 1 to iy 2 inches, and 
upon enlarging this opening to the diameter of 1 cm., the underlying arach- 
noid and cerebral cortex tended to protrude, indicating the high degree of 
intracranial pressure. This opening was quickly enlarged for fear a rupture 
of the cortex would occur by allowing the brain to be protruded under 
high pressure. Over the upper portion of the brain exposed w r as a mass of 
dilated blood-vessels some of them over y s of an inch in diameter — forming 
an angiomatous plexus pressing down upon the cortex of the brain ; the walls 
of these vessels were thickened, whitish, and at the upper portion was a 
bluish background as though this angiomatous mass was the result of a 
former supracortical hemorrhage which was becoming organized with new 
vessel formation. During the operation, a large amount of clear cerebro- 
spinal fluid escaped and continued to drain ; this loss of cerebrospinal fluid 
allowed the cerebral cortex to pulsate but it was still under increased 
pressure in spite of the large loss of cerebrospinal fluid; for this reason, 
4 linen strands were inserted beneath the dura and brought out through the 
temporal muscle and temporal fascia, beneath the scalp, so that this increased 
amount of cerebrospinal fluid w r ould be permanently drained by these arti- 
ficial channels of drainage — as is performed in the operation for external 
hydrocephalus. No attempt was made to remove the angiomatous formation 
lying upon the surface of the brain for fear of hemorrhage ; the over- 
lying bone was removed and this permanent relief of the intracranial pres- 
sure, both by the removal of the bone and by the permanent drainage of the 
increased amount of the cerebrospinal fluid, should cause a definite improve- 
ment of the patient 's condition, mentally as well as physically ; the impair- 
ment of vision should also be improved. The wound w r as closed in the usual 
manner by bringing the temporal muscle and fascia together, and suturing 
them and the scalp in layers with catgut and finally silk. 

Post -operative Notes. — Two hours after operation, the patient was regain- 
ing consciousness and apparently in excellent condition. Patient made an 
excellent operative recovery, so that he was discharged 16 days after opera- 
tion ; incision healed per primam. This patient has been repeatedly exam- 
ined during the past 18 months and his entire condition, especially his emo- 
tional reactions, have been very much improved; he is no longer gloomy 
and morose, he is interested in current events and the affection which he 
formerly did not show toward his relatives has again returned ; the restless- 
ness and "wanderlust" have disappeared and, upon close questioning and 
observation, he is no longer "impelled" to lie, steal or burn things, etc. 

Last Examination (October 20, 1918 — 18 months after operation). — No 
complaints. Mentality and emotional reactions normal. Both decompres- 
sion openings depressed beneath flush of scalp; normal pulsation. Pupils 
equal and react normally. Reflexes — patellar active but equal ; no ankle 
clonus nor Babinski ; abdominal reflexes present and equal. Fundi — retinal 
veins enlarged ; no blurring of details of optic disks. 



5o8 DIAGNOSIS AND TREATMENT OF BRAIX INJURIES 

Be marks. — It would seem that the condition of this patient resulted from 
a brain injury at birth associated with a subdural hemorrhage, particu- 
larly over the left cerebral cortex, in the form of a supracortical layer 
of hemorrhage ; this supracortical blood-clot became organized and, instead 
of forming a cyst or fibrous mass, developed a large mass of blood-vessels 
and thus there was formed an angiomatous tumor mass lying upon the left 
cerebral cortex. As a result of the diffuse subdural hemorrhage, the normal 
stomata of exit of the cerebrospinal fluid in the cortical veins, sinuses, etc., 
became blocked more or less incompletely and, as the result of this blockage, 
there has been an increase of the normal amount of cerebrospinal fluid within 
the cerebrospinal canal, and thus there was formed a condition of mild 
external hydrocephalus, just as results following a mild meningitis. The 
result of this increase of the cerebrospinal fluid has been to increase the 
normal intracranial pressure and thus the signs of this increased intra- 
cranial pressure were revealed in the fundi and by a measurement of the 
pressure of the cerebrospinal fluid at lumbar puncture by means of the 
spinal mercurial manometer : the irritative presence of a supracortical 
angiomatous mass in the left temporo-sphenoidal area was sufficient, with 
the increased intracranial pressure due to the mild external hydrocephalus, 
to exert an irritative effect upon the cerebral cortex and thus convulsive 
seizures occurred. The first operation of right osteoplastic exploration 
sufficiently lessened the increased intracranial pressure so that convulsions 
no longer occurred in spite of the presence of the local irritative effect of 
the angiomatous tumor mass; however, as the patient became older and the 
cortical nerve cells developed more and more qualitatively, the still remain- 
ing intracranial pressure was of sufficient amount to pervert their normal 
development and particularly to impair the emotional stability, which 
is the most susceptible to increased intracranial pressure, whereas a distinct 
mental impairment does not occur unless the intracranial pressure becomes 
very high (this is true also of both motor and sensory impairments) . There- 
fore, this patient could have been considered normal both physically and 
mentally, upon superficial examination, and yet he was definitely impaired 
emotionally and from this standpoint, medically, he was in reality not respon- 
sible for his conduct — no more so than if he were suffering from the toxic 
condition following typhoid fever, alcoholism and the other conditions which 
render one's emotional conduct irresponsible. If the increased intracranial 
pressure in this patient had not been relieved and especially the direct 
pressure of the overlying tumor mass, the emotional instability would un- 
doubtedly have progressed, convulsions would probably have returned from 
the cortical irritation and later the mentality have become affected, so that 
this patient would eventually hare been classed among patients mentally 
and emotionally deranged : if then the increased intracranial pressure was 
not relieved and even if it were relieved at this late date, the prognosis 
would be most doubtful. Even at the time of operation upon this patient, 
the symptoms and signs of an incipient dementia praecox could have been 
considered and this patient could very easily have been classed as being so 
affected. Naturally, sufficient time has not elapsed to warrant a definite 
opinion regarding the prognosis of this patient, but his condition has so 



CHRONIC BRAIN INJURIES 509 

improved since the operation that the result has been most gratifying and 
encouraging ; any patient, however, who has passed through a similar history 
must be considered as temporarily damaged and a period of time of at least 
5 years is necessary before a competent opinion of the prognosis is possible. 

C. Mental derangement. 

Case 128. — Old severe brain injury associated with a depressed fracture 
of the vault, an increased intracranial pressure and melancholy. Institu- 
tional care. Partial craniectomy; drainage of supracortical hemorrhagic 
cyst. Excellent improvement and recovery. 

No. 043.— John. Fifty years. White. Single. Fireman. U. S. 

Admitted May 10, 1913 — 15 years after injury. Polyclinic Hospital. 
Eef erred by Doctor George E. Brewer. 

Operation May 21, 1913 — 11 days after admission. Partial craniectomy; 
drainage of cyst. 

Discharged May 27, 1913 — 7 days after operation. 

Family history negative; no insanity or nervous instability. 

Personal History. — Fifteen years ago, while working as a marine engi- 
neer on a fire-boat of the New York City Fire Department, patient was struck 
over the top of the head by a wooden beam ; ' ' everything became very dark, ' ' 
but patient does not think he lost consciousness; no bleeding from nose, 
mouth or ears, and after lying down for several hours, he was able to con- 
tinue his work. During the following 2 weeks, he had severe headaches, 
vomited daily, and finally became so disoriented that he roamed about the city 
in a dazed, semiconscious condition — unable to find his way home ; patient 
was arrested and then transferred to Bellevue Hospital, and after remain- 
ing there one month, he was sent to Bloomingdale Asylum, White Plains, 
where he remained for a period of 11 months — the diagnosis being ' ' melan- 
cholia"; while there, patient now says "I was not crazy enough to be in 
an asylum and yet not well enough to be at work. ' ' Finally he escaped from 
Bloomingdale, found light work, but was unable to hold a position longer 
than several weeks. Patient was again found roaming the streets, and this 
time he was confined in Central Islip Insane Asylum — the diagnosis being 
"melancholia"; he later escaped from this instituton, went out West and 
was finally confined in an asylum from which he escaped — only to be confined 
in another asylum — the diagnosis always being "melancholia"; whenever 
he became sufficiently lucid later to realize his surroundings, he would 
escape. Seven months ago while in a Massachusetts State Insane Hospital, 
patient was trephined in the median line of the frontal bone and an area of 
bone iy 2 inches removed ; the longitudinal sinus, however, was torn, requir- 
ing immediate packing and no further exploration or operation was possible. 
(It would be interesting to know just what benefit could be derived by 
an operation of this character and in this location, especially since the dura 
was not opened.) Patient finally obtained his discharge from this hospital 
4 months later, and after remaining at home for 2 months in a fairly rational 
condition, he was referred for examination. 

Examination upon admission (15 years after injury V — Temperature. 
98.6°; pulse, 70; respiration, 20; blood-pressure. 142. Well-developed and 
nourished, but apparently much older than his real age. Morose and de- 



5 io DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

pressed, showing no interest in surroundings and current events. Memory 
for recent events was impaired and all affection for relatives lost. Complains 
of dull heaviness throughout the head and spells of mild vertigo. No 
weakness of the arms, legs or face ; no sensory impairment except the loss of 
the sense of position of toes of both feet — more on left than on right (he could 
not tell whether left big toe was being pressed upward or downward) . Pupils 
equal and react normally. Reflexes negative. Fundi — retinal veins rather 
full; no edematous blurring of details of optic disks, which were rather 
whitish and their margins slightly irregular and ill-defined; both physio- 
logical cups rather shallow from new tissue formation — that is, mild signs of 
a secondary optic atrophy (indicating a former increased intracranial pres- 
sure) . Lumbar puncture — clear cerebrospinal fluid under slightly increased 
pressure (approximately 12 mm.) ; Wassermann test negative and cell count 

only 6 cells per c.mm. X-ray 
(Doctor A. J. Quimby) — 
" slight flattening of top of 
vault beneath which the 
underlying bone was rather 
blurred — possibly an old line 
of fracture at this point " 
(Fig. 150). 

Treatment. — It was con- 
sidered advisable to explore 
the top of the vault as sug- 
gested by the X-ray, espe- 
cially since the neurological 
examination indicated the 
underlying area of the brain 
as the site of a possible 
organic lesion — the loss of 
the sense of position of the 
toes of both feet, and espe- 
cially those of the left foot; 
the signs of a mild increase of the intracranial pressure as revealed by the 
ophthalmoscope and at lumbar puncture were also suggestive of an intra- 
cranial lesion, and yet not high enough to warrant a subtemporal decom- 
pression first. 

Operation (11 days after admission). — Exploratory craniectomy: trans- 
verse curvilinear incision of the scalp 3 inches across the longitudinal sinus 
and over the vertex of the vault; a small trephine opening was made on 
either side of the sinus, these openings enlarged by rongeurs and finally 
the intervening bridge of bone over the sinus removed; in this area just 
to the right of the longitudinal sinus, the inner table of the vault was 
thickened irregularly as though resulting from a former fracture of the 
inner table in this area; both parietal bones at the coronal suture were 
thickened to a diameter of % inches and were depressed at this point to 
a depth of % °f an inch. Just to the right of the longitudinal sinus, the 
dura bulged slightly and upon opening it, there was exposed an underlying 




Fig. 150. — Old depressed fracture of vertex of vault in a 
patient becoming mentally deranged. Removal of bony 
depression and an underlying cortical cyst permitted an 
excellent recovery. 



CHRONIC BRAIN INJURIES 511 

cyst, the size of an olive, lying beneath the longitudinal sinus and betweeen 
the falx cerebri and the right cerebral cortex itself — indenting the latter 
but not to the extent of causing a cortical laceration, and adhering to the 
cortex (the result of a former supracortical hemorrhage in this area and 
most probably due to a tear of the overlying longitudinal sinus at the time 
of the injury). It was considered surgically unwise to attempt the removal 
of this cystic formation en masse, so that it was therefore merely punctured, 
and its outer wall excised, allowing 3 c.c. of straw-colored fluid to escape 
under tension ; it was believed that the removal of the overlying bone would 
permit a sufficient local decompression to occur, so that, even if the cyst 
should refill, it would not exert its former compressive effect. Usual closure 
with 2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery so 
that he could be discharged 7 days after the operation; incision healed 
per primam. 

Examination at discharge. — Temperature, 98.8°; pulse, 68; respira- 
tion, 20 ; blood-pressure, 148. Mental and emotional condition the same as 
before operation. No complaints, however, except soreness at the site of 
the operation. Operative site nas healed perfectly and pulsates normally. 
It is interesting to note that the sense of position of the toes of both feet 
has returned and thus showing that the direct local compression of the 
cystic formation was responsible for this sensory impairment. Pupils equal 
and react normally. Reflexes negative. Fundi — retinal veins still slightly 
enlarged ; the mild signs of secondary optic atrophy are naturally still pres- 
ent and will always remain, in that there has been a definite tissue formation 
about and in the optic disks due to the former edematous changes of the 
optic disks resulting from an increased intracranial pressure. 

Examination (June 5, 1914 — 13 months after operation). — No com- 
plaints ; no longer dull headaches or dizzy spells. Relatives state that he is 
a "changed man." Patient has been working for the past 6 months as 
watchman at a crossing of the Long Island Railroad. Careful physical 
examination negative, except for the mild signs of old secondary optic 
atrophy. Site of operation depressed and pulsates normally. Sense of 
position of toes of both feet normal. During the past 4 years, this patient- 
has been examined at irregular intervals ; his associates at work 011 the rail- 
road state that he is rather ' ' eccentric, ' ' but otherwise he does his work well 
and is not considered abnormal; "he is not talkative and does not make 
friends easily." 

Last Examination (September 16, 1918 — 64 months after operation). — 
No complaints; works daily. Operative area depressed and pulsates nor- 
mally. Sense of position of toes of both feet normal. Reflexes negative. 
Fundi — retinal veins of normal size; mild signs of old secondary optic 
atrophy persist. 

Remarks. — The history of this patient is very instructive : at the time 
of the supposed trivial "bump" on the top of the head, patient undoubtedly 
had a fracture of the inner table of the skull with a small tear of the under- 
tying longitudinal sinus, so that it bled subdurally and more on the right side 
— forming a blood-clot between the falx cerebri and the right cerebral cortex ; 



5 i2 DIAGNOSIS AND TREATMENT OF BRAIX INJURIES 

as the result of the organization of this blood-clot, a cystic formation 
occurred, causing the sensory impairment (ascertained years later) . The in- 
creased intracranial pressure, due to the intracranial hemorrhage and the 
resulting chronic cerebral edema, was sufficient to produce the emotional 
instability in this patient chiefly one of depression and melancholia. — to the 
extent that the patient was mentally unbalanced and therefore requiring 
institutional care. Although possibly a sufficient period of time- has not 
elapsed to warrant an excellent prognosis, yet the improvement continues up 
to the present time, over 5 years since the operation, so that the outlook is 
very hopeful to say the least. This case emphasizes the necessity of most 
careful neurological examinations — particularly the ascertaining of the 
presence or not of an increased intracranial pressure, and then if any local- 
izing signs can be demonstrated, the early recognition of their importance 
realized and the appropriate treatment advised. 

(This case is also interesting from another point of view: at the time 
of the original injury — 15 years before operation and when the patient was 
confined first in Bellevue Hospital, he was put upon the sick list of the 
Fire Department of Xew York City and finally a full pension granted to 
him: the patient, however, never received any of this pension — by devious 
political ways, the money reached a ''ward-heeler"' registered under the 
same name, and thus for 15 years this patient was deprived of money due 
him. Upon recovering his emotional stability, patient learned of this injus- 
tice, brought suit against the City of Xew York and in 1916 — 3 years after 
operation, the patient was given the money due him with interest.) 

Case 129. — Old severe brain injury, with a depressed gunshot frac- 
ture of the vault, associated with an increased intracranial pressure and 
a mental derangement of the dementia praecoid type. Right subtemporal 
decompression and removal of the depressed area of vault ; supracortical 
angioma. Only a temporary improvement. 

Xo. 620.— John. Twenty years. White. Single. School. U. S. 
Admitted May 26. 1916 — 1 years after injury. Alexian Brothers Hos- 
pital. Elizabeth. X. J. Eeferred by Doctor Otto Wagner. 

Operation June 29, 1916 — 33 days after admission. Right subtemporal 
decompression : removal of depressed area of vault. 
Discharged July 16. 1916 — IT days after operation. 
Family history negative. 

Personal History. — Always well and strong until 1 years ago. when the 
patient was accidentally shot twice through the head — one bullet entering the 
right temporal region and passing obliquely upward and out through the 
vertex in the midline, while the other bullet entered beneath the left eye and 
lodged just anterior to the sella turcica. Unconscious for several days ; seven 
general convulsions occurred and then he made a slow and gradual recovery; 
never the same, however, as before the injury. Patient complained of dull 
headache during the following 2 years, and then a noticeable change in the 
patient appeared: he no longer complained of headaches, but he became 
morose and gloomy, showed no interest in anything, no longer affectionate — 
so that the diagnosis of incipient dementia praseox was considered. During 
the past 2 years, this condition has remained practically the same until one 



CHRONIC BRAIN INJURIES 513 

month ago, when the patient again complained of headaches and has vomited 
several times; no convulsions, however, since the injury itself. 

Examination in consultation with Doctor Wagner. — Temperature, 98.8° ; 
pulse, 70 ; respiration, 18 ; blood-pressure, 130. Well-developed and nour- 
ished. Apparently rational when questioned, but he would lapse quickly into 
moods of depression — no longer interested in anything. Complains of con- 
tinuous throbbing headache, chiefly over the frontal region. Irregular area 
of bone over midline of vault just posterior to vertex — the scar of exit of one 
bullet ; small scar just below the left orbit. No motor nor sensory impair- 
ment; no impairment of joint sense nor of sense of position of extremities. 
No astereognosis nor apraxia. No signs of subtentorial lesion — nystagmus, 
ataxia nor Romberg sign, etc. Pupils equal and react normally. Reflexes : 
patellar exaggerated — left more than right; left exhaustible ankle clonus 
and left Babinski ; abdominal reflexes present and apparently equal. Fundi 
— retinal veins dilated ; nasal halves of both optic disks obscured by edema. 
Lumbar puncture — clear cerebrospinal fluid under increased pressure 
(approximately 18 mm.) ; Wassermann test negative and cell count was 
8 cells per c.mm. X-ray report — "Posterior to the scar at the vertex of 
vault is an irregular area of bone due to an old fracture and beneath it is 
an irregular light area, almost 2 inches in diameter; a bullet can be seen 
just anterior to the sella turcica and its pathway is indicated by fragments 
of lead — this being the injury of the second bullet at the time of the 
original cerebral injury. ' ' 

Treatment. — Although the mental and emotional condition of the patient 
was such that the diagnosis of dementia prsecox was very possible, still on 
account of the signs of an increased intracranial pressure, the definite history 
of cranial injury and the X-ray picture showing a lesion beneath the frac- 
ture of exit at the vertex of the vault, it was decided to) perform first a 
right subtemporal decompression and then to explore at the site of the 
fracture on the vertex. 

Operations (4 years after injury). — First. Right subtemporal decom- 
pression : usual vertical incision, bone removed, and no complications. Dura 
very much thickened, vascular and tense — numerous large sinuses through- 
out dura, giving it a corrugated appearance ; upon incising dura, clear 
cerebrospinal fluid spurted to a height of 2 inches, revealing a very 
' ' wet, ' ' edematous cortex with many newly formed vessels lying upon it and 
in a cystic formation of the arachnoid (being very similar to the patho- 
logical picture resulting from a supracortical hemorrhage and observed 
most frequently in conditions of cerebral spastic paralysis due to a supra- 
cortical hemorrhage at the time of birth). A large amount of cerebrospinal 
fluid escaped so that the cortex protruded less tensely and pulsated at the 
end of the operation. Usual closure with one drain of rubber tissue inserted. 
Temporary sterile gauze dressing applied. 

Second Operation. — A transverse curvilinear scalp incision now made 
just posterior to the vertex and extending across the median line: a 
small trephine opening made on either side of the longitudinal sinus. 
these openings enlarged and then the bone overlying the sinus itself was 
removed. A most unusual dural picture presented itself: large dura! 
33 



5 i4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




sinuses, the size of lead pencils, extended to the right of the longitudinal 
sinus, forming a tumor mass similar to a "bunch of fish-worms" (the cause 
for the irregular light area shown in the X-ray pictures). The intradural 
pressure in this area did not seem to be abnormally increased (due to the 
preceding subtemporal decompression), and, therefore, the dura was not 
opened ; the danger also of attempting such a procedure on account of the 
angiomatous mass would have been very great indeed. Usual closure with 
2 drains of rubber tissue inserted. Duration, 90 minutes. 

Post-operative Notes. — Patient made an excellent operative recovery so 

that he was discharged from 
the hospital 17 days after 
operation ; operative inci- 
sions healed per prima in. 
During the following 12 
months, patient was im- 
proved in that he no longer 
complained of headaches and 
was of a more cheerful dis- 
position; he was, however, 
unable to concentrate men- 
tally. Twelve months after 
operation, patient entered 
again into a state of depres- 
sion, no longer interested in 
his surroundings, and was 
eventually recommended for 
institutional care — the pres- 
ent diagnosis being dementia 
prseeox. X-ray picture ' ' dis- 
closes the bullet and its 
pathway of entrance; also 
three silver clips within the 
oval decompression area ' ' 
(Fig. 151). 

Remarks. — Whether this 
patient, if operated upon early, could have been spared this emotional 
instability cannot be assured ; it does seem reasonable, however, that if a 
lessening of this increased intracranial pressure could have been secured 
and especially if the supra-cortical hemorrhage resulting from the bullet 
injury in its intracranial passage could have been drained by a subtem- 
poral decompression immediately after the injury, that the patient would 
have had a much greater chance of ultimate recovery of his former nor- 
mality; merely because this patient now has the symptoms and signs of 
dementia precox, this does not mean that his condition is one primarily 
and essentially a true dementia precox — with its most hopeless prognosis. 
This case merely emphasizes the necessity of proper surgical treatment 
following a cranial injury having marked signs of increased intracranial 
pressure ; practically all gunshot injuries penetrating the intradural cavity 



I 





Fig. 151. — Revolver bullet and its pathway beneath, left orbit 
in a patient shot twice in the head; mental derangement. Tem- 
porary improvement only, following a right subtemporal decom- 
pression, which can also be seen in the rontgenogram. 



CHRONIC BRAIN INJURIES 515 

produce a subdural hemorrhage and this hemorrhage should always be 
drained; this is especially true when it is associated with an increased 
intracranial pressure, due not only to the hemorrhage alone but to the 
resulting traumatic cerebral edema. 

The presence of the bullet intracranially and in the neighborhood of 
the sella turcica is not exhibiting any clinical signs and naturally no 
attempt should be made to remove it. Even if it should be within the 
brain substance, any operation performed to remove it would merely 
increase the damage to the patient, and if no signs of its presence existed 
before the operation, these signs would most probably appear after the 
operation and as a result of the operative damage to the cerebral tissues. 

Case 130.— Old severe brain injury associated with a depressed fracture 
of the vault and with signs of an increased intracranial pressure ; emotional 
and mental impairment of the traumatic dementia type. Left subtemporal 
decompression. Improvement. 

No. 1045. — Albert. Thirty-two years. White. Married. Pattern-maker. 
United States. 

Admitted December 3, 1918 — 27 years after injury. Audubon Hospital. 
Referred by Doctor E. L. Kellogg. 

Operation December 18, 1918 — 15 days after admission. Left subtem- 
poral decompression. 

Discharged January 5, 1919 — 18 days after operation. 

Family history negative. 

Personal History. — Patient was considered a normal child until cranial 
injury. When 5 years of age (27 years ago) , patient was kicked over the left 
frontal region by a horse; immediate loss of consciousness; no bleeding 
from nose, mouth or ears ; patient was kept in bed for one week, when the 
irregular depressed bone of 1% inches in diameter was removed ; an excel- 
lent recovery apparently, and the patient was considered normal until 6 years 
ago (at the age of 26 years), when he began to complain of headache, inabil- 
ity to ' ' concentrate his mind, ' ■ early fatigue and an increasing depression 
and melancholia ; he refused to work for fear of it " hurting ' ' him. This 
condition of mental and emotional deterioration increased, so that during 
the past 2 years he will not associate with anyone, sits by himself sullenly, 
displays no affection toward friends or relatives, says he is worried and 
has even suggested suicide as a means of relief ; that is, he displays many 
of the symptoms and signs of dementia prsecox, and also of traumatic 
dementia, in that his memory has become impaired, says childish and ' ' fool- 
ish 77 things and must now be accompanied upon the street for fear he 
will become lost. He has always complained of dull headache and a heavy 
feeling in his head. 

Examination upon admission (27 years after injury). — Temperature, 
98.6° ; pulse, 70 ; respiration, 18 ; blood-pressure. 132. Fairly well-developed 
and nourished. Very much depressed and melancholic: answers questions 
after hesitation and with much difficulty ; definite impairment of memory and 
says "I fear I shall not last long." Over the left frontal bone is an irregu- 
lar scar and a definite depression at the site of the former trephine opening. 
No paralyses or sensory impairments. Hearing negative; otoscopic exam- 



516 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






ination negative. Pupils equal and react normally. Reflexes — patellar 
active, right possibly greater than left ; no ankle clonus but suggestive right 
Babinski; abdominal reflexes present and equal. Fundi — retinal veins 
enlarged ; nasal margins of both optic disks blurred by edema ; both physio- 
logical cups shallow from new tissue formation and both optic disks rather 
pale from an increased formation of new tissue — a very mild degree of sec- 
ondary optic atrophy, right possibly more advanced than left ; visual acuity, 
however, was 15/20 in each eye. Lumbar puncture — clear cerebrospinal fluid 
uuder increased pressure (14 mm.) ; Wassermann test negative and cell 
count was 6 cells per c.mrtL Urine examination negative. X-ray (Doctor 

A. J. Quimby) — "an irreg- 
ular bony defect of left 
frontal area ; no linear frac- 
ture visible" (Fig. 152). 

Treatment. — On account 
of the definite signs of an 
increased intracranial pres- 
sure, it was considered advis- 
able to perform a left 
subtemporal decompression 
in the hope that the condi- 
tion of this patient could be 
improved; the long period 
since the injury and the 
marked emotional and men- 
tal impairment are naturally 
factors which make the 
ultimate prognosis very 
doubtful ; the absence of con- 
vulsions, however, is en- 
couraging. 

Operation (27 years after 
injury) . — Left subtemporal 
decompression : usual inci- 
sion, bone removed, and no complications. Dura whitish and under moderate 
tension; upon incising it, clear cerebrospinal fluid spurted to a height of 
1 inch and upon enlarging the dural opening, a very "wet" edematous 
cortex tended to protrude but did not rupture; much cerebrospinal fluid 
escaped, permitting the cortex to recede before the end of the operation. 
In the arachnoid and about the cortical vessels in the sulci was a grayish 
fibrous induration — the residue of a former subarachnoid hemorrhage. No 
laceration or cystic formation visible. U'sual closure with 2 drains of rubber 
tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful operative recovery; incision healed 
per primam and the patient was discharged on the eighteenth day 
after operation. 

Examination (February 20, 1919 — 2 months after operation). — Accord- 
ing to the father and the patient himself, he has made a marked improve- 




Fig. 152. — Irregular bony defect of left frontal area in a 
patient having an old depressed fracture and subsequent 
mental derangement. Improvement following an operative 
lowering of the increased intracranial pressure. 



CHRONIC BRAIN INJURIES 517 

ment in that he has been working the past week, is showing an increasing 
interest in his work, and says "lam going to do well. ' ' Father states that 
patient is not so depressed, is becoming interested in his two children and in 
every way he is more like his former self. Decompression area is flush with 
the surrounding scalp. Reflexes active but otherwise negative — there being 
uo left Babinski elicitable. Fundi — retinal veins rather full ; very indistinct 
edematous blur of lower nasal quadrant of both optic disks — much less than 
before the operation ; the new tissue formation of the mild secondary optic 
atrophy naturally still persists. 

Last Examination (December 8, 1919 — 12 months after operation). — 
Father writes that patient has been working daily and no ' ' troublesome 
complaints ; in many ways, he is a changed man. ' ' 

Remarks. — It would be most surprising and unusual if this patient would 
make an excellent recovery both emotionally and mentally, and yet I feel 
he has an excellent chance of being markedly improved ; it may be of only 
temporary duration, but even then the operation would be justified if his 
condition were only improved for a period of a year or more, and the con- 
dition retarded and delayed. In the absence of the cranial injury, and 
particularly if there were no signs of an increased intracranial pressure, 
then the diagnosis would undoubtedly be that of dementia prsecox with its 
hopeless prognosis; the ascertaining, however, of the signs of a definite 
increase of the intracranial pressure immediately withdraws this patient 
from that large hopeless group of patients having dementia prsecox and 
makes it possible for him to be improved by means of a mechanical lessening 
of this increased intracranial pressure ; his condition may not be ultimately 
improved and yet the operation gives him a definite chance. A report of this 
patient will be made later after a period of several years has elapsed. 

Merely removing a small area of depressed bone of the vault without 
opening the dura widely in these patients having an increased intracranial 
pressure associated with the depressed fracture of the vault, is very incom- 
plete surgical treatment, and it may be considered of only temporary benefit 
to the patient. The ideal time for the appropriate treatment of these patients 
having an increased intracranial pressure is immediately after the cranial 
injury, when the shock has subsided; then, the increased intracranial 
pressure can be first relieved by a subtemporal decompression and drainage, 
and then the depressed area of the vault can be elevated or removed. This 
method of treatment will prevent or, at least, tend to prevent such unfor- 
tunate results as in this patient. 



PART III 

ACUTE AND CHRONIC BRAIN INJURIES IN 
NEWBORN BABIES AND CHILDREN 



CHAPTER XIII 

General Considerations. — In newborn babies, acute brain injuries are 
the result of trauma at the time of parturition, which may be either a diffi- 
cult prolonged one with and without the use of instruments or even a 
so-called ' ' precipitate ' ' birth, in that the delivery is an unusually rapid one 
complicated by a rupture of the thin- walled cortical veins; damage to the 
delicate intracranial structures may also occur in an apparently normal 
labor; these observations and diagnoses have been frequently confirmed 
by autopsies. 

It has long been recognized that prolonged difficult labor, and especially 
if instruments for delivery are necessary, is of risk to the immediate recovery 
of life of the child ; this danger to life itself has been comparatively slight, 
but if the death of the child did occur, then it was realized (and occasionally 
confirmed at autopsy) that the intracranial contents had been so badly 
damaged that even if the baby had recovered, yet it could not have been a 
normal child mentally and physically, and therefore it was merely con- 
sidered an unavoidable and unfortunate result of a difficult labor, the object 
being to secure a living mother damaged as little as possible and then a living 
child, if possible. If the child was successfully resuscitated immediately 
after birth, so that it was considered normal and not damaged intracranially, 
the prognosis' as to future normality was naturally excellent — and in fact, 
this is the usual result. Even if the child was drowsy and stuporous for a 
period of ten days and longer, when it did not cry as newborn babies ordi- 
narily do, or if it was of the excitable restless type and crying almost con- 
tinuously and whether slight convulsive twitchings of any part of the body 
were present or not — this condition during an indefinite period of days fol- 
lowing delivery was usually a temporary one only, so that it was not con- 
sidered as being permanently harmful to the future of the child ; in other 
words, the child ' ' would grow out of it." And in the majority of babies with 
this immediate post-traumatic history, the condition does gradually disap- 
pear and fortunately no ill-effects are later to be observed due to the entire 
absorption of the intracranial hemorrhage and cerebral edema. There is a 
small percentage of babies, however, in which this happy result does not 
occur ; either they remain in a comatose coudition with and without 
convulsive seizures for several days and then die — and at autopsy an 
extensive subdural and usually a supracortical layer of hemorrhage is 
revealed associated with a very "wet" edematous condition of the brain. 
or they apparently become normal within several days, and are con- 
sidered so until the sixth, seventh, eighth or ninth month later, when 
it is realized that the child is not developing as a normal child should — 
is not holding up its head, does not attempt to grasp and to hold things, 
notices little if anything, etc., and as it becomes older this retardation 
and impairment, both physically and mentally, becomes more and more 
marked; even at this late date of months and especially without careful 

5-i 



522 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

examinations, the parents may be told that nothing" is really ' ' wrong ' ' with 
the child, ' ' merely retarded, ' ' and ' ' it will grow out of it. ' ' These children, 
however, rarely do become normal when the condition is the result of a large 
intracranial lesion at the time of birth — usually a supracortical layer of 
hemorrhage with little or no primary damage to the brain itself, and in the 
babies which cannot "take care of" this large amount of hemorrhage and 
cerebral edema by the natural means of absorption, then the effects of this 
intracranial condition associated with a definite increase of the intracranial 
pressure are later shown in a general retardation of the development of the 
child, both mentally and physically. Unless this increased intracranial pres- 
sure of hemorrhage and excess cerebrospinal fluid is relieved early — if not 
immediately after birth then within several days, or if the condition is per- 
mitted to continue until the latter months of the first year and even later, 
then its lowering by means of a subtemporal decompression, and if necessary 
a bilateral decompression is essential in order to permit a marked improve- 
ment to occur, although the longer this increased intracranial pressure is 
allowed to continue, either through ignorance, carelessness or mistaken diag- 
nosis and judgment, just so much more permanent is the cerebral impairment 
in its mental and physical results. The differential diagnosis at this late date 
is between that of lack of development of the cerebral cortex or its pyramidal 
tract fibres (the so-called Little's Disease), a meningitic and meningo- 
encephalitic destructive process associated or not with embolic or thrombotic 
complications, hereditary lues (less than 2 per cent.) and then the condition 
of intracranial hemorrhage at the time of birth and of such large amount, 
that the natural means of absorption have not sufficed to permit the normal 
lowering of the increased intracranial pressure of the hemorrhage and the 
chronic cerebral edema, resulting from a partial blockage of the stomata of 
exit of the cerebrospinal fluid in the cortical veins, sinuses, etc., by the 
organization of this layer of supracortical hemorrhage ; and thus in reality, 
producing a mild external hydrocephalus similar, but in milder form, to the 
condition of hydrocephalus resulting from an extensive meningitic process, 
which does not block the ventricles and therefore producing the more 
common type of external hydrocephalus. These chronic brain injuries 
occurring in children who become impaired both mentally and physically 
and particularly of the type of cerebral spastic paralysis, will be discussed 
later in detail under the heading of chronic brain injuries in children. 

In the acute brain injuries with and without a fracture of the skull 
occurring in children under 12 years of age, the immediate effects of 
intracranial lesions can be withstood much more successfully than in adults — 
the initial shock is less, the reaction is much stronger and prolonged, and 
they can recover from intracranial trauma as far as immediate life is con- 
cerned much more easily and with fewer immediate complications than 
is possible in adults ; but th e remote effects, however, of serious intracranial 
lesions in children, and especially associated with a prolonged increase of the 
intracranial pressure, are more permanent in these patients later in life, and 
they form a very influential factor in the future development of the child — 
both mentally and physically. It is this remote factor and result of 



IN NEWBORN BABIES AND CHILDREN 523 

intracranial injuries in childhood which have been rather neglected 
and overlooked. 

A. Acute Brain Injuries in Newborn Babies. — It is not uncommon for 
acute brain injuries to occur in newborn babies during parturition — usually 
a difficult labor with and without the use of instruments, but it is rare for 
these intracranial lesions to be associated with a fracture of the skull; 
occasionally depressed fractures of the vault and of the so-called "ping- 
pong 1 " type result, but it is most unusual for a frank linear fracture of 
the flexible newly-formed bone to be demonstrated — by rontgenograms, 
operation or at autopsy. If there is present in these newborn babies any 
abnormality of the bones of the skull, then it is almost invariably a diastasis 
and separation of the suture lines with and without their overlapping, one 
over the other; the suture line most frequently involved is the median one 
between the two parietal bones and overlying the longitudinal sinus, which 
may thus be torn, permitting an intracranial hemorrhage of varying size to 
form over the cortex of one or both hemispheres 1 of the brain — and this is 
a very common type of intracranial hemorrhage occurring in newborn babies 
as a result of the change of continuity of the bones of the vault. This 
separation of the suture lines and the overlapping of the adjacent bones 
rarely persist after birth longer than hours or days at the most and they 
may be present only during the active second and third stages of labor, and 
then the bones resume their normal relation and position — but after the 
damage to the sinus has resulted. This is the reason why careful bimanual 
examination of the heads of these children and the still later rontgenograms 
in various planes only infrequently demonstrate the presence of the over- 
lapping of the lines of suture. The frontal bone in its posterior relation to 
the parietal bones to form the coronal suture and the occipital bone in its 
anterior relation to the parietal bones to form the lambdoidal sutures are 
the next most common sites for the overlapping of their respective suture 
bones, and yet intracranial lesions only occasionally follow since there are 
here no underlying sinuses. 

If the longitudinal sinus is not torn and it is possibly one of the most 
frequent causes of the condition, then the next most usual source of the 
supracortical hemorrhage is a rupture of the delicate supracortical veins 
of either or both cerebral hemispheres, as a result of a severe venous stasis 
and congestion occurring during a prolonged difficult labor ; the hemorrhage 
may be only a local one — the size of a ten-cent piece or a silver quarter, 
and yet the associated cerebral edema following the cerebral trauma is always 
present, and may in many patients be the more serious factor. It is thus seen 
that the intracranial hemorrhage in these newborn babies rarely occurs in 
the cerebral cortex and in the brain itself, and therefore causing a primary 
destruction of brain tissue (and no regeneration), but the hemorrhage is 
almost always subdural but supracortical — lying upon the surface of the 
brain — and its damage to the underlying cerebral cortex is one of pressure. 
due both to the hemorrhage itself and to the resulting cerebral edema ; that 
is, if this supracortical hemorrhage and excess cerebrospinal fluid can be 
successfully drained and thereby the increased intracranial pressure be 
permanently lowered, then these babies will have an excellent opportunity 



524 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

to recover — not only the immediate recovery of life but that of future nor- 
mality — and now is the ideal time for the appropriate treatment of these 
patients; later in life the impaired condition can be improved, but rarely 
is a perfectly normal child then possible. 

No doubt, there are many cases of latent intracranial hemorrhage at 
birth, where there are no marked clinical signs of the presence of the lesion 
and where the natural means of absorption are sufficient to ' ' take care of ' ' 
the mild increase of the intracranial pressure — and a normal child is pos- 
sible. And on 1he contrary, later impairments occurring in certain children 
in adolescence, such as mild mental retardation, emotional instability and 
even epilepsy itself, may be due to a mild intracranial hemorrhage at the 
time of birth ; its mild clinical signs not recognized or being overlooked, and 
the later appearance of signs indicative of a former intracranial lesion 
with resulting adhesions, etc., and — it is then usually too late to obtain a 
very satisfactory result by any treatment now known — the child may 
approximate normality but scarcely ever attain it. The treatment should be 
preventative whenever possible ; if not possible, then at least corrective. 

Although the labor itself in these babies developing an intracranial 
hemorrhage at the time of birth need not be a prolonged difficult one asso- 
ciated with the use of forceps, yet it very frequently is ; also, the condition 
itself occurs most often in first babies of full term. The condition occasion- 
ally results even from a so-called normal delivery, although a difficult labor 
with and without the use of instruments is the usual history obtained. 
Any newborn baby which does not behave normally within the first two or 
three days after birth, in that it is unusually drowsy and even stuporous, 
and especially in the presence of convulsive twitchings of any part of the 
body — that baby should be carefully examined for definite signs of an intra- 
cranial hemorrhage; a lumbar puncture is of the greatest diagnostic im- 
portance ; if free blood is found in the cerebrospinal fluid, not only is the 
diagnosis confirmed but an excellent means of drainage is thus afforded 
unless the pressure is high — over 15 mm. as registered by the spinal mer- 
curial manometer and associated with tense fontanelles and positive oph- 
thalmoscopic findings. Daily repeated lumbar punctures with removal 
of 10-12 c.c. of bloody cerebrospinal fluid may be performed upon a number 
of consecutive days until the pressure of the cerebrospinal fluid does not 
exceed 10 mm. and in these patients an excellent result is frequently 
obtained. In those babies, however, in whom the increased pressure of the 
cerebrospinal fluid reaches a height of 15 mm. and even higher, and especially 
when associated with tense fontanelles and positive ophthalmoscopic find- 
ings of increased intracranial pressure, then a modified subtemporal decom- 
pression and drainage is most advisable in order to obtain not only a living 
child but of the greatest importance — a normal child later. 

Through the usual vertical incision of the subtemporal decompression 
with retraction of the split temporal muscle^ a small area of bone — not 
larger than a silver quarter, may be rongeured away and then the dura 
carefully opened ; the supracortical hemorrhage and excess cerebrospinal 
fluid can thus be easily drained ; a small drain of rubber tissue is inserted 
beneath the temporo-sphenoidal lobe into the middle fossa of the base, in 



IN NEWBORN BABIES AND CHILDREN 



525 




^y 



order to continue the drainage for one or two days — the usual length of 
time sufficient to lower the intracranial pressure permanently. No anes- 
thesia or primary anesthesia alone is required and only at the very begin- 
ning of the precedure — in order to insure the operative asepsis. In some 
selected patients whose pressure of the cerebrospinal fluid does not exceed 
18 mm., then through a similar but smaller vertical incision of 2 cm. over 
the squamo-parietal suture line, an opening through the membranous suture 
line may very easily and quickly be made with a scalpel and tissue forceps, 
the dura carefully incised and a drain of rubber tissue inserted. The objec- 
tions to this method are that the drainage opening is higher and therefore 
nearer the motor area of the cerebral cortex with a consequent greater 
danger of operative damage to the underlying highly developed and more 
important portions of the brain, and also that the drainage itself is not so 
satisfactory as when the drain can be 

inserted into the middle fossa at the /*" 

base. This method of drainage I 

through the suture line is no longer 
used in our clinic. Naturally, the 
right side of the head in these patients 
is operated upon, if the parents are 
both right-handed and if there are no 
localizing signs indicative of a greater 
lesion upon the opposite side of 
the head. 

Case 131. — Recent depressed frac- 
ture of the left parietal area of the 
vault of the skull in a newborn child ; 
localizing symptoms and signs. Re- 
moval of depressed area of vault. Ex- 
cellent recovery. 

No. 957. — Olga. Five weeks. 
White. United States. 

Admitted March 4, 1918, 5 weeks 
after injury. Polyclinic Hospital. Referred by Doctor J. V. D. Young. 

Operation March 5, 1918. Removal of depressed bone. 

Discharged March 10, 1918, 5 days after operation. 

Family history negative. 

Personal History. — First baby, full term, instrumental delivery. Imme- 
diately after birth, it was noted that the left parietal area of the vault was 
depressed two inches in diameter and one-half inch in depth. No bleed- 
ing from nose, mouth or ears; no mastoid eechymoses. Child was rather 
drowsy and stuporous, but otherwise apparently normal; no clinical signs 
of localization referable to the left cerebral cortex; no convulsive seiz- 
ures. Fontanelles rather tense and bulge slightly. 

First Examination. (February 26, 1918 — I weeks after birth V — Tem- 
perature, 98.8°; pulse, 104; respiration, 28. Well-developed child. Rather 
jsleepy and drowsy — does not cry upon being disturbed. In left parietal 
area of the vault is a depression of almost one-half inch in depth and of two 






Fig. 153. — Large depressed fracture of left 
parietal area following an instrumental delivery 
in a baby of five weeks of age, showing a definite 
weakness of the right side of the body. Complete re- 
covery following the removal of the depressed bone. 



526 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

inches in diameter (Fig. 153) ; no pulsation palpable. Fontanelles rather 
tense but pulsation normal. Definite weakness of right arm, slight weakness 
of right leg, and a possible flaccidity and flatness of the lower portion of right 
side of face (the cortical type of facial paralysis). Sensation — no impair- 
ment could be elicited. Pupils equal and react normally. Reflexes : patellar 
right possibly more active than left ; no ankle clonus but double Babinski ; 
abdominal reflexes cannot be elicited. Fundi: retinal veins full and tor- 
tuous — left possibly more than right ; definite edematous blurring and hazi- 
ness of nasal margins of both optic disks — left greater than right. Lumbar 

puncture — clear cerebro- 
spinal fluid under slightly 
increased pressure (10 mm.) . 
X-ray (Doctor G. W. Wel- 
ton ) — ' ' depressed area of 
left parietal bone of one and 
one-half inches in diameter; 
no comminution of fracture 
observed" (Fig. 154). 

Treatment. — In the pres- 
ence of a depressed area of 
the vault producing the defi- 
nite localizing signs of weak- 
ness of the opposite side of 
the body and the fear that 
convulsive seizures might 
later occur as a result of the 
irritation of the underlying 
cerebral cortex, it was con- 
sidered advisable and im- 
perative to elevate and, if 
necessary, to remove the 
depressed area of bone 

Fig. 154. — Depressed fracture of left pariefo-squamous area fSvVn'pTi clirmlrl limm V»Aor» 
in a newborn baby producing a right hemiparesis. Complete [ " mCJ1 Sn0lUa naVe Deen 
recovery following an operative removal of the depressed bone, performed within Several 

days after birth). 
Operation (March 5, 1918 — 5 weeks after injury). — Removal of de- 
pressed area of vault, primary anesthesia alone being administered : verti- 
cal incision of two inches over depressed area of bone of the left parietal 
region; scalp retracted and an effort made to elevate the depressed bone 
by means of a small periosteal elevator being inserted through the line of 
fracture at the periphery of the depression ; this attempt was not successful 
and the depressed bone was now rongeured away to a diameter of one and 
one-half inches. The intact underlying dura which had been depressed 
so that it was concave, now welled upward and assumed its normal convex- 
ity. Dura slightly tense but pulsated normally, and therefore it was not 
opened ; it was of normal appearance. Usual closure with two drains of 
rubber tissue inserted down to dura. Fine interrupted silk sutures were used 
to approximate the scalp in one layer. Duration, 25 minutes. Post-operative 



IN NEWBORN BABIES AND CHILDREN 527 

notes : uneventful recovery. Within 48 hours, the definite weakness of the 
right side of body had become less marked and at the end of 4 days no 
impairment could be ascertained. Child became less drowsy and stuporous 
and presented no abnormality. 

Examination at discharge (5 days after operation). — Temperature, 
98.6°; pulse, 98; respiration, 28. Operative incision healed per primam; 
it is flush with the surrounding scalp and pulsates normally. No weakness of 
the right side of the body can be elicited. Pupils equal and react normally. 
Reflexes : patellar — active, right possibly greater than left ; no ankle clonus 
but double Babinski ; abdominal reflexes absent. Fundi : retinal veins slightly 
enlarged ; very faint obscuration of nasal margins of both optic disks. 

Examination (October 20, 1918 — 7 months after operation). — Xo com- 
plaints ; " a normal baby in every way. ' ' Operative area slightly depressed ; 
normal pulsation ; some new bone formation at periphery of the bony open- 
ing. Pupils equal and react normally. Reflexes : patellar — active but equal ; 
no ankle clonus but indefinite double Babinski; abdominal reflexes — both 
depressed but equal. Fundi negative. 

Last Examination (March 6, 1919 — 12 months after operation). — Xo 
complaints. Operative area slightly depressed and of smaller diameter due to 
new bone formation at periphery ; only slight pulsation palpable. Reflexes 
negative. Fundi negative. 

Remarks. — This is the type of patient having a depressed fracture of 
the vault at the time of birth which is frequently not elevated or removed, 
in the belief that the normal convexity of the vault will be later approximated 
by the growth of the brain gradually forcing the depressed area of bone 
outward ; that is, these depressed fractures of the vault occurring in new- 
born babies "will take care of" themselves. Xo doubt a large number of 
these patients make excellent recoveries, both as to immediate impairment 
and to future complications, but it is most unwise to permit these patients 
to run the great risk of serious complications and especially of convulsive 
seizures, before an attempt is made to elevate or remove the depressed area 01 
bone ; the risk of the operation is practically nil, especially when the dura is 
not opened and it never is, unless the intracranial pressure is high, and then 
it is better surgical judgment to perform a subtemporal decompression first 
and then remove the depressed area of the vault. Unless the depressed 
area of bone becomes elevated by itself within a week after birth, and espe- 
cially if clinical signs of its presence are indicated by an increased intra- 
cranial pressure and the localizing signs of paralysis, convulsive twitchings, 
etc., then the local operation of elevation or removal of the depressed area 
should be performed without delay; to wait until the underlying brain 
elevates the depressed area of the vault by its normal pulsation — the brain 
being allowed to act as a "crow-bar," as I recently heard it expressed by 
a children's specialist — is hardly a duty to be imposed upon the brain an 1 
one which may result disastrously to its future normality. 

Case 132. — Acute severe brain injury in a newborn baby associated with 
a supracortical hemorrhage and convulsive twitchings; an increased intra- 
cranial pressure. Loft subtemporal decompression and drainage. Ex- 
cellent recovery. 



S 28 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

No. 731.— William. Twelve hours. White. U. S. 

Admitted November 23, 1916 — 12 hours after birth and injury. Poly- 
clinic Hospital. Referred by Doctor M. A. Swiney, Bayonne, N. J. 

Operation November 24, 1916 — 24 hours after admission and 36 hours 
after birth. Left subtemporal decompression and drainage. 

Discharged December 2, 1916 — 8 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — First child, full term, head presentation, very difficult 
labor of 48 hours, requiring instruments. Weight — ten and a half pounds. 
Very difficult to resuscitate and he remained in a drowsy stuporous condi- 
tion for 2 hours, when convulsive twitchings of the right facial muscles and 
of the fingers of the right hand occurred and persisted for five to seven 
minutes each time ; six hours after birth, a convulsive seizure of the right 
side of the body began in the right arm and lasted for four minutes ; twenty 
minutes later, a second convulsive seizure of the right side of the body ap- 
peared and it became a general convulsion, lasting for 2 minutes. On the 
way to the hospital, another general convulsion began in the right arm, then 
the right leg, and finally both sides of the body convulsed tonically and then 
clonically for a period of almost 4 minutes. 

Examination upon admission (12 hours after birth and the injury). — 
Temperature, 104° ; pulse, 120 ; respiration, 34. Conscious but rather 
drowsy. Over the posterior portion of the right frontal bone was a small 
hematoma — the size of an English walnut ; rather tense. No bleeding from 
nose, mouth or ears. Left orbit swollen and ecchymosed; left subcon- 
junctival hemorrhage. An apparent left facial paralysis of the peripheral 
type (left forehead muscles being involved). No paralyses of the extremi- 
ties of either side of the body. Otoscopic examination negative. Fon- 
tanelles moderately tense and slightly bulging. Pupils equal and react to 
light normally. (During the examination the muscles about the right eye 
and right side of mouth twitched spasmodically and also the fingers of the 
right hand, but no convulsive seizure occurred.) Reflexes — patellar active 
but equal; no ankle clonus but double Babinski; abdominal reflexes could 
not be elicited. Fundi — nasal halves and temporal margins of both optic 
disks obscured by edema ; retinal veins enlarged. Lumbar puncture — clear 
cerebrospinal fluid under increased pressure (approximately 12 mm.) ; cell 
count was 5 cells per c.mm. — no red blood corpuscles being* observed. X-ray 
(Doctor W. H. Stewart) — "no fracture revealed." 

Treatment. — In the absence of blood in the cerebrospinal fluid at lum- 
bar puncture and since the intracranial pressure was not registered as being 
above 15 mm. and there having been a cessation of the convulsive seizures 
during the past 2 hours, it was decided to treat the child expectantly in 
the hope that the intracranial condition could be "taken care of" by the 
natural means of absorption; the usual routine treatment was used — con- 
sisting of an ice-bag to the head, external warmth and absolute; quiet. The 
condition of the child remained practically the same during the next 12 
hours, and it was thought that an excellent recovery both of life and of nor- 
mality would be possible ; 18 hours after admission and 30 hours after birth, 



IN NEWBORN BABIES AND CHILDREN 529 

the third general convulsion occurred, beginning in the right arm, then the 
right leg, and finally both sides of the body ; a fourth similar convulsive 
seizure occurred two hours later after which it was observed that the 
right arm and right leg were more lax and limp than the left arm and left 
leg ; a lumbar puncture at this time removed clear cerebrospinal fluid under 
an increased pressure (approximately 14 mm.) and the cell count contained 
numerous red blood corpuscles ; the ophthalmoscopic examination persisted in 
revealing an edematous obscuration of the nasal halves and temporal margins 
of both optic disks, but not a measurable swelling to the degree of papilledema 
(1 or 2 diopters). On account of these signs of an increasing intracranial 
pressure with the definite localizing signs pointing to the left cerebral 
hemisphere, it was now considered advisable to perform a left subtemporal 
decompression and drainage. 

Operation (36 hours after birth and injury and 24 hours after admis- 
sion). — Left subtemporal decompression and drainage (no anesthesia being 
required except codeine, grs. 1/12, hypodermically) : usual vertical incision, 
bone removed, and no complications. Dura very tense, bulging and bluish ; 
upon incising it, bloody cerebrospinal fluid spurted to a height of 2 inches, 
and upon enlarging the incision a thin layer of supracortical hemorrhagic 
clot welled through the dural opening, revealing a very "wet," edematous 
cortex which tended to protrude but did not rupture ; one small supracortical 
vein lying in a sulcus ruptured owing to the high cerebral tension, but its 
bleeding was quickly stopped by the application of a small piece of temporal 
muscle (thus causing the rapid coagulation and blockage of the bleeding 
point). Much bloody cerebrospinal fluid escaped, permitting the cortex to 
recede at the end of the operation and to pulsate almost normally. LTsual 
closure with 2 drains of rubber tissue inserted. Duration, 16 minutes. 

Post-operative Notes. — Uneventful recovery; profuse discharge of cere- 
brospinal fluid ceased 18 hours after the operation so that the drains were 
then removed. No convulsive seizures or localized twitchings occurred after 
the operation and the definite weakness of the right arm and right leg could 
not be elicited within 12 hours after the operation; the edema of both 
optic disks subsided, so that on the second day after operation only an 
indistinct blurring of the lower nasal margins of the optic disks could be 
observed. The child rapidly became more lively and on the third day 
after operation, he cried for the first time. 

Examination at discharge (8 days after operation). — Temperature. 
99° ; pulse, 116 ; respiration, 32. Apparently normal in every way. Hema- 
toma over the left frontal bone has disappeared. Weakness of the left side 
of face has lessened so that it can only be elicited while the child is crying. 
Decompression area bulges slightly beyond the flush of scalp ; normal pulsa- 
tion. No weakness of right arm or of right leg can be obtained. Pupils 
equal and react to light normally. Reflexes — patellar active but equal ; 
no ankle clonus but double Babinski persists (practically normal for young 
babies, as it appears in a large number of them) ; abdominal reflexes — 
depressed but equal. Fundi — retinal veins enlarged; lower nasal margins 
of both optic disks slightly blurred by edema. 

Examination (February 20, 1918 — 15 months after operation). — Child 
34 



53o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

did not hold its head up until 8 months after birth and did not sit up until 
the thirteenth month; it is now crawling about and attempting to stand 
and to walk, but it is unable to do so. No convulsive seizures have occurred 
since the operation. Child is possibly not so alert mentally as it normally 
should be. Decompression area flush with surrounding scalp ; normal pulsa- 
tion. No weakness of the extremities or sensory impairments ascertained. 
Reflexes : active but otherwise negative ; a tendency possibly to a right Babin- 
ski. Fundi negative. 

Last Examination (June 6, 1919—31 months after birth and opera- 
tion) .—Child has progressed rapidly during the past year ; he is able to walk, 
but has some difficulty in balancing himself. (Fig. 154a.) He is able to say 
a number of words and small sentences. No convulsive seizures have 
occurred ; mentally not so alert and interested in his toys and surroundings 

as is possibly normal. Decompression area 
slighty depressed beneath the flush of scalp; 
some new bone formation at the periphery ; nor- 
mal pulsation. Reflexes active but otherwise nega- 
tive. Fundi negative. 

Remarks. — In the hope that this baby would 
be able to "take care of" the intracranial lesion 
of cerebral edema and intracranial hemorrhage 
( and many newborn babies are able to absorb the 
milder conditions), the operation of decompres- 
sion and drainage was postponed 24 hours in this 
patient, and it was only upon the development of 
the signs of an increasing intracranial pressure 
with the return of the convulsive seizures that 
made the operation an urgent one — not only in 
order to obtain a recovery as far as life was con- 
cerned, but also to obtain a normal child if 
possible. The lesion as disclosed at the operation 
was one from which a normal child is possible, 
and the steady marked improvement in this baby 
would make us hopeful that a normal child will be possible ; sufficient time, 
however, has not elapsed to permit an accurate statement to be made, and 
it will require at least 15 years and even longer for the later condition 
of this patient to be ascertained ; the end result may not be a normal child 
and may at most only approximate one, and yet I believe that the opera- 
tive indication remains the same, and if children of this character can be 
spared the frightful condition of spastic paralysis in its various forms 
and mental impairment in marked degree, then there can be no question 
as to the advisability of the operative procedure. These patients should 
impress the profession with the need and the importance of most careful 
obstetrics and that any newborn baby, with or without a difficult labor, 
which does not appear to be as normal as it should be immediately after birth 
and particularly in the presence of convulsive seizures, then these babies 
should be most carefully examined, both with the ophthalmoscope and by 
means of repeated lumbar punctures, in order to ascertain the presence or 




Fig. 154a. — Patient 2M years after 
left subtemporal decompression. 






IN NEWBORN BABIES AND CHILDREN 531 

not of an increased intracranial pressure — whether due to an intracranial 
hemorrhage or severe cerebral edema, and if it is thought that a normal child 
is not possible without the cranial operation of decompression and drainage, 
then this latter procedure should be performed with no hesitancy as the 
best and only means of obtaining the greatest ultimate improvement in these 
selected babies. The use of repeated lumbar punctures and thus the drain- 
age of the intracranial hemorrhage and excess cerebrospinal fluid in selected 
babies should always be attempted as advocated by Doctor J. B. Sidbury, 
Wilmington, N. C. 

If the left subtemporal decompression and drainage had not been per- 
formed upon this patient, it is very probable that the weakness of the right 
arm and right leg would have progressed into one of paralysis, the general 
convulsive seizures have become more severe and more frequent, and the 
death of the child possible or— in many respects even a greater misfortune 
and calamity, the survival of a child who later becomes the typical spastic 
hemiplegic with or without convulsive seizures and mentally impaired — a 
condition than which nothing is worse. 

Case 133. — Acute severe brain injury in a newborn baby associated with 
cortical, supracortical and subtentorial hemorrhages and with high intra- 
cranial pressure. Bilateral decompression and drainage. Death; autopsy. 

No. 575. — Baby Y. Forty-seven hours. White. U. S. 

Admitted May 6, 1916 — 47 hours after birth. Polyclinic Hospital. 
Referred by Doctors R. T. Frank and R. Ottenberg. 

Operations May 6, 1916—2 hours after admission. Bilateral subtemporal 
decompression and drainage. 

Died May 7, 1916 — 21 hours after operation. 

Family history negative. Personal history negative. 

Present Illness. — First baby, full term, difficult labor requiring high for- 
ceps ; head presentation ; weight — 8 lbs. Great difficulty in resuscitation on 
account of the extreme cyanosis. Several contusions of the scalp over the 
occipital area observed. Child very drowsy and did not cry, but it was con- 
sidered normal until 4 hours after birth, when localized convulsive twitchings 
began in the right arm, then the right leg and the entire right side of the 
body ; apparently no loss of consciousness ; this twitching of the right side of 
the body lasted for two or three minutes and then a second one occurred — 8 
minutes later. Daring the following six hours, twentj^ of these convulsive 
twitchings of the right side of the body occurred, and then ten hours after 
birth a general convulsion appeared and continued for 6 minutes ; two hours 
later, it was noticed that the left arm and left side of face were paralyzed 
and that the left leg was weak. The general convulsions continued until 43 
hours after birth — always beginning in the right arm and the right leg and 
then becoming general ; the paralysis of the right arm and of the right side 
of face persisted. 

Examination at consultation (47 hours after birth and injury'). — 
Temperature, 104° ; pulse, 130 ; respiration, 42. Well-formed baby ; semi- 
conscious. Entire left side of body paralyzed. Slight twitchings of the 
right facial muscles and of the fingers of the right hand. Contusion and 
ecchymosis of the scalp overlying the occipital area, No bleeding from nose. 



532 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

mouth or ears. Both f organelles tense and bulging ; slight pulsation palpable. 
Pupils slightly enlarged and react to light sluggishly, right possibly larger 
than left. Reflexes all very much depressed; suggestive double Babinski; 
abdominal reflexes absent. Fundi — retinal veins widely dilated ; edematous 
blurring of the nasal halves and temporal margins of the optic disks but 
no measurable papilledema. Lumbar puncture — bloody cerebrospinal fluid 
under increased pressure (approximately 14 mm.). 

Treatment. — The presence of the blood in the cerebrospinal fluid and 
under increased pressure, associated with the convulsive seizures and the 
left hemiplegia, made the operation of cranial decompression and drainage 
advisable in the hope that a recovery of life might be obtained and if so, 
then the greatest ultimate recovery and improvement by the immediate 
drainage of the intracranial hemorrhage and a permanent lowering of 
the increased intracranial pressure ; the fact, however, that the general 
condition of the child was very poor and practically moribund from the 
possible complication of medullary edema made the operation of doubtful 
value, and yet it was considered as giving the child its only chance of recov- 
ery (an opinion now realized to be a mistaken one, and it would have been 
better judgment not to have operated in the hope that the child itself 
might recover from this extreme condition, so that the operation could later 
be safely performed ; as in older children and adults, the condition of medul- 
lary edema indicates the early death of the patient — operation or no opera- 
tion). Before operation, the right pupil became widely dilated and the left 
pupil markedly contracted. 

Operations (49 hours after birth). — Left and right subtemporal decom- 
pression and drainage (no anesthesia being necessary) ; first, left decompres- 
sion: usual vertical incision, bone and newly formed bone removed, and 
no complications. Dura very tense and bulging, and upon incising it blood- 
tinged cerebrospinal fluid spurted under high pressure ; the underlying 
edematous cortex protruded and bulged under such high pressure that a small 
rupture occurred below the Sylvian fissure; throughout the cortex were 
numerous punctate hemorrhages. No pulsation visible. Owing to this ex- 
treme intradural pressure, it was decided to perform immediately a right 
subtemporal decompression. Usual closure with 2 drains of rubber tissue 
inserted. Second, right subtemporal decompression and drainage : usual 
vertical incision, newly formed bone of underlying vault removed, and no 
complications. Dura very tense and bluish, and upon incising it a dark 
currant-jelly supracortical clot welled through dural opening; almost 3 
ounces of this clot were evacuated, exposing a very edematous and hemor- 
rhagic cortex which bulged under high pressure. Slight pulsation of cortex 
now visible. Usual closure with 2 drains of rubber tissue inserted. Dura- 
tion, 50 minutes. 

Post-operative Notes. — The condition of the haby was apparently not 
worse than before the operation; profuse drainage of blood and cerebro- 
spinal fluid saturated the dressings, requiring their change within 8 hours ; 
it was then observed that the child could move the left arm, which had been 
paralyzed before the operation. The temperature, however, remained 
around 103 °, while the pulse did not descend lower than 140, and the 



IN NEWBORN BABIES AND CHILDREN 533 

respiration below 48. Fourteen hours after the operation, the general con- 
dition of the child became worse in that the temperature ascended to 105.4, 
the pulse- and respiration-rates to 156 and 64, respectively, and finally 
becoming imperceptible until the child died — a death typical of medullary 
edema, 21 hours after operation. 

Autopsy. — In the tissues of the scalp over the median portion of the 
occipital bone was much free blood. No fracture of the skull ascertained, 
but the longitudinal sinus underlying the junction of the parietal bone 
with the occipital bone was torn — most probably due to an overlapping of 
these bones at the time of birth and the resulting tear of the underlying 
sinus. Over the cortex of the posterior portions of both cerebral hemispheres 
and much more over the right one, was a layer of supracortical hemorrhage, 
1 cm. in thickness and extending forward to the right decompression opening 
but not within 2 inches of the left decompression opening. Beneath the ten- 
torium and about the medulla and cerebellum was a large amount of this 
same currant- jelly clot which had compressed directly the medulla and 
therefore the early signs of medullary edema and death. Numerous punc- 
tate hemorrhages throughout the cortex of both hemispheres, but no cortical 
laceration except at the site of the left decompression. Ventricles negative. 

Remarks. — If this patient could have been operated upon several hours 
earlier and before the definite signs of an acute medullary edema had 
appeared, it is possible that a recovery of life might have been obtained, 
and yet with the extensive subtentorial hemorrhage as disclosed at opera- 
tion and causing a direct compression of the medulla itself, it is very doubt- 
ful if this patient could have recovered under any circumstances and under 
any treatment. The early onset of medullary edema was undoubtedly due 
to this extensive subtentorial hemorrhage — the most serious of all intra- 
cranial lesions, especially when associated with an extensive cerebral edema. 
It is now realized that in patients having brain injuries, either at the time 
of birth or later in life, and the condition of medullary edema resulting from 
high pressure has occurred, then these patients, with but very rare excep- 
tions, all die — no matter what the treatment, with and without operation, 
and it is a mistake of judgment to advise any cranial operation upon these 
patients in this late stage in the belief that they are being afforded a chance of 
recovery ; they are beyond recovery once the condition of medullary edema 
becomes definitely established, and it is only in those patients who are 
entering into the stage of medullary edema that an operation may afford in a 
small percentage of them a definite chance of recovery. 

Owing to the compensatory lessening of the increased intracranial pres- 
sure in these newborn babies by means of a separation of the lines of suture 
of the skull and the elasticity of the dura itself and the bulging fontanelles, 
the intracranial pressure as registered by the ophthalmoscope and the spinal 
mercurial manometer at lumbar puncture is always less than occurs in simi- 
lar cases occurring in older children and in adults, in whom the lines of 
suture are united, the fontanelles closed and the dura inelastic. It is for this 
reason that the pressure of the cerebrospinal fluid in this patient did not 
register higher than approximately 14 mm. and the ophthalmoscope disclosed 
only an edematous blurring of the nasal halves and temporal margins of the 



534 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

optic disks, but no measurable swelling to the extent of a papilledema —let 
alone the more advanced degree of "choked disks" — this latter condition 
being a most rare observation in patients having brain injuries and due 
to the fact that these patients usually die from the high intracranial pressure 
before the condition of ' ' choked disks ' ' can be produced, unless the increas- 
ing intracranial pressure is a, slow and gradual one, as may result from 
hemorrhage of the middle meningeal artery and causing a huge extradural 
clot to be formed ; in this manner the increasing intracranial pressure would 
be similar to that caused by tumor formation, only much more rapid when 
due to hemorrhage. If the ventricles, however, should be blocked and a 
mild internal hydrocephalus be produced, then the condition of "choked 
disks ' ' is very easily and very early produced ; fortunately, this ventricular 
blockage in traumatic cases is rare. 

It would have been better surgical judgment if the first decompression 
had been performed upon the right side of the head rather than upon the 
left side, and the clinical signs of paralysis of the left side of the body 
and the larger right pupil indicated that the pressure over the right cerebral 
cortex was greater than over the left cerebral cortex; that is, the greater 
pressure over the right cerebral cortex was producing the paralytic dilata- 
tion of the ipsolateral right pupil and the paralysis of the left side of the 
body, whereas the less pressure of the left cerebral cortex was causing an 
irritative constriction of the ipsolateral left pupil and the irritative con- 
vulsive seizures of the Jacksonian type of the right side of the body. If 
the right subtemporal decompression had been performed first and the supra- 
cortical clot evacuated, it would then have been possible to have performed 
the left decompression without the operative damage of rupture of the 
underlying cortex due to the extreme intradural pressure. 

Case 134. — Acute severe brain injury in a newborn baby associated 
with an increased intracranial pressure due to subdural, supracortical and 
subtentorial hemorrhages and cerebral edema. Bilateral decompression and 
drainage. Death. Autopsy. 

No. 1048. — Ninomiya. Six hours. Yellow. Japanese. U. S. 

Admitted (born December 4, 1918, 12 noon), Audubon Hospital. Re- 
ferred by Doctor E. A. Drummond. 

Operations : 1st, December 5,1918 (10 p.m. ) — 34 hours after birth. Right 
subtemporal decompression and drainage. 2nd, December 6, 1918 (11 a.m.) 
— 13 hours after first operation. Left subtemporal decompression 
and drainage. 

Died December 9, 1918 — 65 hours after second operation. 

Family history negative. 

Personal History. — Patient is first child, full-term baby, difficult labor 
but no instruments used ; mother was given pituitrin, causing a precipitant 
labor ; difficulty in resuscitating child, otherwise no abnormalities noticed. 
Four hours after birth, slight twitchings of the left side of the face began 
and these gradually extended to include the left arm and the left leg; 
no definite weakness of the left side of the body observed at this time. 

Examination in consultation with Doctor Drummond, December 4, 1918, 
6 p.m. (6 hours after birth). — Temperature, 101.4 °; pulse, 140; respira- 






IN NEWBORN BABIES AND CHILDREN 535 

tion, 38. Fairly well-developed and nourished Japanese baby girl. Dur- 
ing the examination, a convulsive seizure occurred in that muscular twitch- 
ings of the left side of face began, then the left arm and the left leg 
jerked spasmodically and finally the entire right side of the body twitched — 
the whole attack not lasting more than one minute. A large fluctuat- 
ing hematoma of 2 inches in diameter and very tense, extended over the 
right parieto-occipital area; otherwise no external evidence of head in- 
jury. Anterior fontanelle slightly bulging and tense. Both legs slightly 
stiff, but no weakness of the) arms and legs ascertained. Pupils equal and 
react to light normally. Reflexes — patellar exaggerated, left possibly 
greater than right ; no ankle clonus but suggestive double Babinski ; abdom- 
inal reflexes absent. Fundi — retinal veins enlarged; nasal half of right 
optic disk and nasal margin of left optic disk blurred by edema. Lumbar 
puncture — blood-tinged cerebrospinal fluid under slightly increased pres- 
sure (9 mm.). 

Treatment. — In the hope that the slightly increased intracranial pressure 
due to subdural hemorrhage and cerebral edema could be "taken care of" 
by the natural means of absorption and also, if the dura were torn, by the 
hemorrhage and cerebrospinal fluid escaping through the vault to form 
the hematoma of the right parieto-occipital area, it was considered better 
judgment to treat the child expectantly in the hope that the convulsive 
twitches would quickly cease and the increased intracranial pressure be 
lowered. (It would have been better surgical judgment to have performed 
either repeated lumbar punctures and spinal drainage or the operation of 
subtemporal decompression and drainage at this time.) 

Examination (December 5, 1918 (9 p.m.) — 33 hours after birth). — 
Temperature, 102°; pulse, 148; respiration, 42. Child is in a weaker 
condition than at preceding examination due to inability to take and 
retain its feedings. Convulsive twitches have continued — occurring at 
least once an hour and always beginning on the left side of face, particularly 
the orbicularis muscles of the left eye which contract spasmodically, then the 
twitching of the left side of the mouth begins, extending to the left arm and 
the left leg, to be followed by slight contractions of the right side of the 
body; during the latter part of these convulsive twitchings, the child fre- 
quently vomits. Definite weakness apparently of the left arm and left leg, 
and the left side of the face is less active. Pupils — right slightly larger than 
left but reaction to light is normal. Reflexes — patellar exaggerated, left 
more than right ; no ankle clonus but double Babinski ; abdominal reflexes 
absent. Fundi — retinal veins full ; nasal half and temporal margin of right 
optic disk and temporal half of left optic disk obscured by edema ; no meas- 
urable swelling of beginning papilledema of the right optic disk could be 
registered. Lumbar puncture — bloody cerebrospinal fluid under increased 
pressure (10 mm.). Anterior fontanelle tense and bulges slightly. The 
hematoma over the right parieto-occipital area remains the same size, but it 
is very tense. 

Treatment. — The signs of an increasing intracranial pressure associated 
with a gradually progressive weakness of the child owing to its lack of 
nourishment made imperative an immediate mechanical relief of the in- 



536 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

creased intracranial pressure by means of a subtemporal decompression and 
drainage as the only hope of the child to recover life and then to approximate 
a normal child. 

First Operation (34 hours after birth). — Right subtemporal decompres- 
sion and drainage (primary anesthesia only being used) : usual vertical 
incision, bone removed, and no complications; the Doyen perforator and 
burr were not used as the squamo-parietal suture could be incised by the 
scalpel and the rongeurs easily inserted beneath the bone edge — thus facili- 
tating the removal of bone. Upon incising the dura Avhich wasi very tense, 
bloody cerebrospinal fluid spurted to a height of 1 inch; upon enlarging 
this dural opening, the tense underlying cortex protruded and ruptured for 
a distance of 1 cm., owing to the high cerebral tension. The cortex con- 
tained so many punctate hemorrhages that it had the appearance almost of 
liver tissue. Much subdural and subarachnoid hemorrhage escaped, permit- 
ting the cortex to pulsate feebly. The inner surface of the dura was lined by 
a layer of clotted blood. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 28 minutes. 

Post-operative Notes. — Child did not have a convulsive twitch until 
9 hours after this operation, when they began this time on the right side 
of the face, particularly in the right orbicularis muscles, and then extended 
into the right arm and the right leg, but no twitchings of the left side of the 
body at all. Profuse discharge of bloody cerebrospinal fluid into the dress- 
ings of the right subtemporal decompression and drainage ; the decompres- 
sion area, however, remained tense and bulging and no pulsation was visible. 
At an examination eleven hours after operation, the left pupil was slightly 
larger than the right and the right reflexes were now more active than the 
left ; the fundi, however, disclosed the nasal halves of both optic disks as being 
blurred by edema. The anterior fontanelle was again tense and bulging. 
It was therefore considered advisable to perform a left subtemporal decom- 
pression and drainage to lessen this increasing intracranial pressure, par- 
ticularly over the left hemisphere ; the child had become definitely weaker 
during the last 12 hours. 

Second Operation (13 hours after first operation). — Left subtemporal 
decompression and drainage : usual incision, bone removed, and no com- 
plications; the squamo-parietal suture was again separated by the scalpel 
and the rongeurs easily inserted for the removal of the bone. Dura rather 
tense and bluish; upon incising it, blood-tinged cerebrospinal fluid welled 
out, exposing a tense cortex over which there was a thin film of subarachnoid 
hemorrhage. The cortex tended to protrude but did not rupture. The 
arachnoid was incised, allowing dark free blood to escape. No cortical lacera- 
tions or hemorrhage visible. The under surface of the dura was covered 
by a layer of blood — similar to the condition of pachymeningitis hemor- 
rhagica interna. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 26 minutes. 

Post-operative Notes. — Owing to the child refusing to take its nourish- 
ment, it became progressively weaker; an intravenous saline was given and 
repeated nutrient rectal enemata, but the general condition of the child did 
not improve ; it made no effort to swallow. The blood-pressure gradually 



IN NEWBORN BABIES AND CHILDREN 537 

descended to 100 and below, and the child finally died, apparently of 
general exhaustion, 65 hours after operation. 

Autopsy. — No fracture of the skull ascertained. Small tear through the 
right parieto-occipital line of suture underlying the hematoma, which had 
formed by the tearing of a vessel running from the bone to the underlying 
sinus; the dura itself had not been ruptured. Over both cerebral hemi- 
spheres was a thin film of subdural and subarachnoid hemorrhage — that is, 
a supracortical hemorrhage ; a layer of clotted blood was adherent to the 
under surface of the dura. With the exception of the operative laceration of 
the cortex underlying the right subtemporal decompression, there were no 
lacerations or extensive cortical hemorrhages ascertained. Beneath the ten- 
torium, there was a large amount of subdural hemorrhage and cerebrospinal 
fluid ; cerebellum and medulla were themselves of normal appearance. Ven- 
tricles negative. 

Remarks. — The progress of this patient was a most interesting one ; natur- 
ally the operation of decompression and drainage should have been performed 
immediately after the onset of the convulsions following the first exam- 
ination, 6 hours after birth ; it was hoped that the hematoma was connected 
with the intracranial cavity and in this manner the intracranial hemorrhage 
and edema could be sufficiently drained together with the natural means of 
absorption, so that a cranial operation would be avoided. In this manner, the 
ideal period for the operation was allowed to pass, the child becoming 
weaker and weaker from lack of nourishment and together' with the severe 
cerebral and subtentorial hemorrhage, an early death occurred. Owing to 
the extensive multiple hemorrhages throughout the cortex, it is doubtful 
whether this child could have become normal, and yet this same acute 
condition has been frequently observed in adults following cranial injuries 
and many of them returned to their former normality ; in children, it would 
seem that they would have a still greater chance of approximating normality 
than adults following brain injuries, as the nerve cells in babies are less 
highly developed than they are in later life. 

The bilateral spasticity, and particularly of the legs, is always a bad 
prognostic sign in these acute cases of brain injuries, not only in babies and 
children, but also in adults; post-mortem examinations of these patients 
usually reveal lesions at the base of the skull, and particlularly of the sub- 
tentorial region — most probably due to a compression of the pyramidal 
tracts themselves and thus the great danger of an associated medullary 
compression and its resulting medullary edema. Few of these patients 
having bilateral spasticity within 12 hours after the brain injury recover 
unless the increased intracranial pressure is early relieved. 

The double Babinski as elicited in this patient is naturally of little or 
no significance, as this reflex is considered normal for babies ; when asso- 
ciated, as it was in this child, with exaggerated patellar reflexes and espe- 
cially unequal ones, then their presence may be considered confirmatory. 

It was interesting to observe the increasing intracranial pressure as 
registered by the spinal mercurial manometer; 6 hours after birth, the pres- 
sure of the cerebrospinal fluid at lumbar puncture was 9 mm., whereas at 
the next test, 27 hours later, the pressure was registered by the spinal mer- 



538 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

curial manometer as 10 mm. The normal pressure for newborn babies is 
4 to 7 mm. and thus we could state with accuracy that the intracranial 
pressure was definitely increased. Naturally, there were the other signs 
of an increasing intracranial pressure, as revealed in the ophthalmoscopic 
examinations of the fundi, the bulging and tenseness of the fontanelles, 
together with the signs of cortical irritation as disclosed by the convul- 
sive twitchings. 

The beneficial effect of the right subtemporal decompression and drainage 
w r as shown in many ways; the convulsive seizures ceased for a period of 
9 hours following the operation, and when they did begin they were limited 
to the right side of the body — that is, to the side of the body controlled by 
the left hemisphere, which had not been satisfactorily decompressed and 
its cortical irritation lessened; similarly, the right pupil which had been 
dilated, due to the paralytic effect of greater compression over the ipsolateral 
cerebral cortex, now became of normal size following the operation, and the 
left pupil gradually enlarged as ascertained at the next examination, 11 
hours after the operation, indicating that the left cerebral cortex was now 
being compressed more than the right ; the improvement of the reflexes and 
the change in their inequality to the opposite side of the body, together 
with the disappearance of the weakness of the left side of the body, is 
very impressive. 

Only the slightest amount of ether was administered — in fact, only a 
"whiff" of it was given while the scalp was incised, and then when the dura 
was opened so that the child would not struggle and cause an increase of the 
cerebral tension. It is surprising how little anesthesia is required for cranial 
operations in babies under 3 months of age ; besides, it is a dangerous factor 
and should be avoided as much as possible. 

The layer of free blood adherent to the inner surface of the dura over- 
lying both cerebral hemispheres shows the first stage of the organization 
of this supracortical blood-clot which becomes firmly adherent to the dura 
and giving the dura later a thickened, fibrous, whitish appearance — becoming 
a firm inelastic membrane which does not expand and thus diminishes the 
lessening of the intracranial pressure which would otherwise be afforded by 
the fontanelles ; these latter cannot bulge and protrude owing to this fibrous 
thickening of the dura and thus the increased intracranial pressure is not 
lessened markedly, so that the development of spastic paralysis and mental 
impairment is later possible in these patients following a supracortical 
hemorrhage at the time of birth, unless early relieved mechanically by means 
of a subtemporal decompression and drainage as was attempted in this 
patient ; in this case, however, the intracranial damage was so great, par- 
ticularly the subtentorial compression and also the extreme general weak- 
ness of the child due to insufficient nourishment, that a recovery of life 
itself could not be obtained ; it is unfortunate, however, that an earlier opera- 
tive attempt to lessen the increased intracranial pressure was not made, 
as the child might then have been enabled to swallow and to retain 
its nourishment. 

B. Acute Brain Injuries in Children. — In children under twelve years of 
age, cranial injuries may be of comparatively trivial character, and yet the 



IN NEWBORN BABIES AND CHILDREN 539 

most serious intracranial lesions often resnlt — with and without a fracture 
of the skull. In these patients, however, a fracture of the vault and even 
of the base occurs much more easily than in adults, and the relative unim- 
portance of the fracture of the skull in brain injuries is not illustrated 
better than in a study of these patients. 

Not only do children withstand better the immediate effects of the cranial 
injury and especially the severity of the initial shock in that their reaction 
is a more vigorous one and thus assuring a higher percentage of immediate 
recovery of life, but it seems that the cardiac and respiratory centres in 
the medulla are more resistant and their circulatory mechanism more 
adaptable to sudden increases of the intracranial pressure; it is for this 
latter reason that the expectant palliative treatment can be used success- 
fully in a larger percentage of children having brain injuries both as to 
the immediate recovery of life and to the future normality than is possible 
in adults in whom not only is the initial shock a most serious factor, but 
the sudden increase of the intracranial pressure is an only too frequent 
cause for early medullary complications of compresson, and even medullary 
edema itself. In this series of brain injuries in children under 12 years of 
age, the expectant palliative method of treatment is alone sufficient and 
eminently satisfactory in over three-fourths of these patients, whereas the 
operative treatment to lower a high intracranial pressure — whether due to 
hemorrhage or excess of cerebrospinal fluid — by means of a subtemporal 
decompression and drainage, is only indicated in about one-fourth of the 
total number of these patients; naturally, and it has been repeated a 
number of times in this book, all depressed fractures of the vault should 
be elevated (and this is more frequently possible than in adults) or removed 
— for fear of future complications and chiefly that of cortical irritation with 
its resulting emotional instability and even epileptiform seizures. 

Cranial injuries, apparently of a very trivial character and of such 
slight importance at the time of the "bump," may cause an intracranial 
lesion of the greatest danger — not only to the immediate life of the child, 
but also in its remote effects, later in life, upon the normal development — 
mentally, emotionally and physically. The following case-history is instruc- 
tive for several reasons: 

On the afternoon of April the 10th, 1917, a little girl of nine years of 
age was returning home from school with her governess ; while crossing 
a street six blocks from her home, she stumbled, bumping the left side of 
her head against the pavement ; she jumped up without the assistance of her 
companion, and although the tears came to her eyes, yet she did not cry ; 
she continued to walk to her home, ate her supper two hours later, and then 
went to bed at nine o'clock. The bump was such a trivial one that neither 
the child nor the governess thought of mentioning it to the mother. At four 
o'clock the next morning (twelve hours after the fall), the child became 
restless and then vomited, but did not complain of its head at that time ; 
four hours later, just before breakfast, it again vomited, and now the child 
complained of a "beating" headache, especially over the left side 0? the 
head. Doctor W. B. Hoag examined the child two hours later to find only a 



540 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



slight tenderness over the left posterior parietal area (the site of the bump), 
and exaggeration of the deep reflexes — the right being possibly greater than 
the left ; the pulse-rate was 90 ; there was no ecchymosis nor bleeding from 
the ear, At a consultation three hours later, the same signs were observed 
and a lessened activity of the right abdominal skin reflexes ; the ophthalmo- 
scopic examination of the fundi was negative; the child complained of a 
general headache and some dizziness upon raising the head ; she was active 
mentally — so much so that she cried bitterly when we suggested her 
removal to a hospital for a four days' observation. She was admitted to 
the Polyclinic Hospital at four o'clock in the afternoon (just 24 hours 
after the injury) ; her pulse-rate at this time was 82. A Rontgen-ray pic- 
ture was now taken by Doc- 
tor G. W. Welton, revealing 
"an irregular line of frac- 
ture extending from the 
occipital protuberance for- 
ward to the left squamous 
bone, but not down to the 
base of the skull" (Fig. 
155). The measurement of 
the pressure of the cerebro- 
spinal fluid at lumbar punc- 
ture by means of the spinal 
mercurial manometer regis- 
tered 16 mm. (normal 5-9 
mm.) ; the fluid was clear. 
During the night the pulse 
gradually descended to 76 
at midnight, 66 at four 
o'clock in the morning and 
at ten o'clock the pulse-rate 
was 58 ; the child had become 
alternately restless and 
drowsy — would awaken with 
a cry, and even scream from the intensity of the headache, and then quickly 
lapse into a mildly stuporous condition from which she could easily be 
aroused ; there was now a definite inequality of the exaggeration of the deep 
reflexes — the right being markedly increased over the left to the degree of 
both a right patellar and right ankle clonus, but no Babinski reflex could 
be elicited; the right abdominal reflexes were now found to be entirely 
abolished; the right-hand grasp was possibly weaker than the left, but 
there was no apparent weakness of the right side of the face or of the 
right leg ; an impaired sensation could not be elicited. An ophthalmoscopic 
examination at this time revealed a marked dilatation of the retinal veins 
and an edematous blurring of the nasal halves and temporal margins of 
the optic disks — possibly greater in the left than in the right eye; there 
was, however, no measurable papilledema. Speech was not impaired nor 
was there present any astereognosis. No reduction of the visual fields 




Fig. 155. — Lenore. Extensive fracture of the vault in a 
little girl of eleven years of age. No complaints following a 
trivial "bump" on the head until eighteen hours afterward; 
then severe headache, vomiting and definite signs of an increased 
intracranial pressure as shown by the ophthalmoscope and the 
spinal mercurial manometer. Operation performed twenty- 
four hours after injury revealed a large extradural hemorrhage 
as indicated in Fig. 157. Recovery excellent. Last examina- 
tion, May 12, 1919 — twenty-five months later — no complaints. 



IN NEWBORN BABIES AND CHILDREN 



54i 



Fig. 156. — Leonore. Shows the posterior oblique incision 
(B-C) used at operation upon this patient. The slight bruise 
of the "bump" is observed at (A). 



could be ascertained and an homonymous hemianopsia was not present. In 
order to relieve the increased intracranial pressure, whether due to cerebral 
edema or to hemorrhage, a rather posterior left subtemporal decompression 
was performed forty-four hours after the bump (Fig. 156) ; a small line of 
fracture extended obliquely downward through the squamous bone, but 
did not reach its base — there- 
fore, no ecchymosis about the s : ■pj^~< si »~-~^ s 
ear nor bleeding from the • /^^^/^ 
external auditory canal ; 
upon rongeuring away the 
squamous bone lying beneath 
the temporal muscle, an ex- 
tradural currant- jelly clot of 
the thickness of 1-1 % inches 
welled up through the bony 
opening (Fig. 157) ; as much 
as four ounces of clotted 
hemorrhage were removed 
with a spoon spatula, allow- 
ing the underlying com- 
pressed dura and brain to rise; the cavity extended upward to the longi- 
tudinal sinus and backward to the tentorium ; a small amount of cerebral 
tissue was found in the upper portion of the clot, so that the dura had 
undoubtedly been torn in that area; the posterior branch of the middle 
meningeal artery had also been torn — the usual source of this type of 
hemorrhage. As the dura 

itself was now no longer \ ^ 

under tension and the under- '•> J 
lying cerebral convolutions 
could be clearly observed, it 
was thought to be better 
surgical judgment not to 
open the dura in this case. 
The temporal muscle and 
fascia were now sutured and 
then the scalp — two rubber 
tissue drains having been 
inserted extradurally. The 
convalescence was unevent- 
ful; pulse-rate became 76 
upon the first day post- 
operative and the other signs noted above quickly faded away so that the 
child made an excellent recovery. She was discharged from the hospital 
upon the tenth day post-operative. Last examination (May 12, 1919 — 2-"> 
months after injury). — Negative; no complaints. 

The main points of this case have been described in detail in order to 
illustrate the apparent triviality of the initial symptoms and signs of many 
brain injuries, with or without a fracture of the skull. Similar cases of 




Fig. 157. — Lenore. Two views of the extra dural hemorrhage 
exposed and removed at operation upon this patient. Note 
the marked depression of underlying brain, and yet the clinical 
signs were most vague within twenty-four hours after injury; 
apparently only a trivial "bump" upon the head. The ront- 
genogram illustrates the advisability of having all head injuries 
— no matter how trivial — examined by the X-ray. 



542 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

an acute intracranial lesion occur not so infrequently but that we should 
always be most careful in our examinations of patients having a history of 
a recent head injury of even the most trivial character, and especially 
is this true of children, who withstand the effects of brain injuries much 
better than adults. There are several tests that should always be employed 
and repeatedly performed if necessary upon these patients, not only to 
locate the site of the brain injury but far more important to ascertain the 
presence or not of an increased intracranial pressure, whether that pressure 
is due to intracranial hemorrhage or to cerebral edema, As is well known, 
the fracture in these patients (if we exclude depressed fractures of the vault 
which should always be elevated or removed) is possibly the most unim- 
portant part to be considered in the treatment, whereas the presence of a 
marked increase of the intracranial pressure, with or without fracture of 
the skull, should immediately cause the patient to be withdrawn from that 
large group of patients properly treated by the expectant palliative method, 
and the advisability of an early operative procedure to relieve the increased 
intracranial pressure should be considered. 

A. Acute cranial injuries of varying degree; no increase of the intra- 
cranial pressure; no operation. Excellent recovery. 

Case 135. — -Acute cranial injury associated with cerebral concussion and 
with mild shock ; no signs of an increased intracranial pressure. Expectant 
palliative treatment. Excellent recovery. 

No. 1012.— Robert. Thirty-three months. White. U. S. 

Admission August 20, 1918. Polyclinic Hospital. Referred by Doctor 
John A. Bodine. 

Discharged August 22, 1918 — 2 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a doorstep, child fell headlong 
to the brick pavement, a distance of 5 feet; loss of consciousness for 10 
minutes ; carried to the hospital by a passerby. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98.2° ; pulse, 130; respiration, 28; blood-pressure, 102. Semiconscious 
but could be aroused, when he would cry intermittently and then fall asleep. 
Contusion of scalp over the right parietal area ; bimanual examination was 
negative. No bleeding from nose, mouth or ears; no orbital or mastoid 
ecchymosis. No paralyses elicited. Pupils dilated and react sluggishly to 
light. Reflexes : patellar — depressed but equal ; tendency to a double Babin- 
ski ; abdominal reflexes absent. On account of the severity of the shock, no 
further examination was made at this time. 

Treatment: for shock, especially external warmth, and the routine 
expectant palliative treatment. Within one hour, the general condition 
had so improved that a more thorough examination was possible. 

Examination (2 hours after admission). — Temperature, 99.2°; pulse, 
96 ; respiration, 28 ; blood-pressure, 110. Drowsy but can answer questions 
perfectly. Otoscopic examination negative. Pupils small, equal and react 
normally. Reflexes — patellar slightly exaggerated but equal; no ankle 
clonus but a bilateral Babinski; abdominal reflexes depressed but equal. 






IN NEWBORN BABIES AND CHILDREN 543 

Fundi — retinal veins slightly enlarged ; no edematous blurring of the mar- 
gins of the optic disks. Lumbar puncture — clear cerebrospinal fluid under 
normal pressure (8 mm.). X-ray (Doctor G. W. Welton) — "negative for 
fracture of the skull. ' ' 

Treatment. — Expectant palliative continued. Child improved so rapidly 
that by the following morning he was sitting up in bed with no complaints ; 
slight tenderness of the bruise of the scalp. Pupils negative. Reflexes 
negative. Fundi — possibly a slight dilatation of the retinal veins; other- 
wise normal. 

Examination at discharge (2 days after admission). — Temperature, 
98.6°; pulse, 82; respiration, 24; blood-pressure, 112. No complaints and 
appears normal in every way. No paralyses nor impairments of sensation. 
Pupils negative. Reflexes negative. Fundi negative. 

Examination (November 4, 1918 — 3 months after injury). — No com- 
plaints. Reflexes negative. Fundi negative. 

Last Examination (May 16, 1919 — 9 months after injury). — No com- 
plaints; "As well as ever." Reflexes negative. Fundi negative. 

Remarks. — This remarkable recuperative ability of children having 
cranial injuries is very common and especially between the ages of 2 and 12 
years; in adults, the initial shock alone is a most serious complication, 
whereas in children of this age they may be in an extreme condition of 
shock immediately following the cranial injury and yet the next day they 
are practically well. Also the ability of these children to "take care of" 
a moderate increase of the intracranial pressure of hemorrhage or excess 
cerebrospinal fluid by the natural means of absorption is another factor 
to be remembered in their treatment — making operative interference a 
less frequent necessity in them than in adults having a similar intra 7 
cranial condition. 

External warmth, particularly heated blankets, is of the greatest value 
in overcoming the effects of the shock in these children — possibly more so 
than in adults. Rectal enemata of hot black coffee alternating each hour 
with normal saline solution is also very satisfactory, as is the codeine 
for restlessness ; as a rule, however, drugs are of little value in children in 
this severe condition of initial shock — less so than in adults. 

Case 136. — Acute cranial injury with cerebral concussion and associated 
with severe shock and with a fracture of the vault, but no signs of an in- 
creased intracranial pressure. No operation. Excellent recovery. 

No. 252.— Charles. Six years. White. School. U. S. 

Admission May 30, 1915, Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Discharged June 5, 1915 — 6 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street, child was struck by an auto- 
mobile and rolled along the cement for a distance of 20 feet ; immediate Loss 
of consciousness; brought to the hospital in the ambulance. 

Examination upon admission (35 minutes after injury ). — Tempera- 
ture, 97.8°; pulse, 136; respiration, 34; blood-pressure, 88. Unconscious: 



544 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



in severe shock with extreme pallor and cold ; chest, abdomen and extremities 
negative. Multiple contusions and abrasions about head with a tense 
hematoma of the size of an egg over the right forehead. No bleeding from 
nose, mouth or ears ; ecchymosis of right orbit but not of either mastoid area. 
Pupils widely dilated and no reaction to light observed. Reflexes 
all abolished. 

Treatment. — No extensive examination made on account of the extreme 
condition of shock, which was immediately combatted with heated blankets 
and hot water bottles ; rectal enemata of hot black coffee (ounces 2) alternat- 
ing with hot normal saline solution ( ounces 2 ) every hour for 8 hours, with 
absolute quiet, in a darkened room. After 2 hours, the condition began to 
improve in that the temperature became almost normal and the pulse and 

respiration descended slight- 
'% ly, while the blood-pressure 
increased to 98; after a 
period of 12 hours had 
passed, his improved condi- 
tion permitted the following 
examination to be made : 

Examination (12 hours 
after admission). — Tempera- 
ture 98.8°; pulse, 102; res- 
piration, 28; blood-pressure, 
108. Semiconscious; of bet- 
ter color and body warmth. 
External condition of head 
and scalp remains the same 
as at preceding examination. 
Xo paralysis elicited. Oto- 
scopic examination nega- 
tive. Pupils of normal size 
and reaction. Reflexes pres- 
ent and equal; no ankle 
clonus nor Babinski; ab- 
dominal reflexes slightly de- 
pressed but equal. Fundi 
negative. Lumbar puncture — clear cerebrospinal fluid under normal pres- 
sure (7 mm.). X-ray (Doctor A. J. Quimby) — "vertical line of frac- 
ture of the right half of the frontal bone extending down into orbital 
plate" (Fig. 158). 

Treatment. — Expectant palliative continued. The improvement in the 
general condition was a rapid one after the first 12 hours, so that the patient 
could be discharged on the sixth day after the injury. 

'Examination at discharge (6- days after injury). — Temperature, 98.6°; 
pulse, 82 ; respiration, 24 ; blood-pressure, 114. No complaints except a 
general soreness of the entire scalp. Hematoma of right forehead is much 
smaller ; no definite areas of tenderness. Pupils equal and react normally. 
Reflexes negative. Fundi negative. 




Fig. 158. — Vertical linear fracture of right half of frontal 
bone, extending into right orbital plate in a patient having 
the symptoms and signs of only concussion. The comparative 
unimportance of the fracture of the skull is well illustrated. 
Excellent recovery. 



IN NEWBORN BABIES AND CHILDREN 545 

Examination (June 4, 1917 — 24 months after injury). — No complaints; 
is considered "perfectly well." Reflexes negative. Fundi negative. 

Last Report (February 26, 1919 — 45 months after injury). — No com- 
plaints; "well and strong; gets along well in school." 

Remarks. — This case illustrates the remarkable ability of children to react 
from the extreme condition of shock following severe cranial injuries ; a 
similar degree of initial shock in an adult would probably have been fatal. 
Not only can children, and especially under 12 years of age, withstand the 
effect of extreme shock in these injuries, but they are able to resist and 
"take care of" by absorption a high degree of intracranial pressure of 
either hemorrhage or excess cerebrospinal fluid, so that the operation of 
subtemporal decompression and drainage is not so frequently indicated in 
them as in adults having a similar condition. 

The most effective anti-shock remedies are external heat by means of 
heated blankets being wrapped about the patient and hot water bottles 
to the extremities and body ; internal heat and stimulation by rectal enemata 
of hot black coffee and hot normal saline solution; codeine and even small 
doses of morphia if the patient is restless; and absolute rest and quiet. 
The patient must not be disturbed by prolonged and extensive neurological 
examinations to ascertain any change of the reflexes, ophthalmoscopic 
examinations, and by no means a lumbar puncture in this period of severe 
shock ; a marked increase of the intracranial pressure cannot be present in 
this severe stage and no treatment other than the expectant palliative one 
can be administered during this period — no matter what the examinations 
might reveal. 

The relative unimportance of the fracture of the skull in these patients 
is well illustrated in this case-history. 

Case 137. — Acute cranial injury associated with a possible depressed 
fracture of the vault of the skull. Exploratory incision of the scalp — no 
depression ascertained Excellent recovery. 

No. 240.— Annie. Fifty-four months. White. U. S. 

Admission May 14, 1915, Polyclinic Hospital. Referred by Doctor 
C. S. Hunt. 

Operation May 16, 1915 — 2 days after injury. Exploratory scalp incision. 

Discharge May 24, 1915 — 8 days after scalp incision. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street, child was knocked down 
by an automobile; unconscious for several minutes; mother brought child 
to the hospital on account of "lump on head." 

Examination upon admission (3 hours after injury). — Temperature, 
98.8°; pulse, 92; respiration, 28; blood-pressure, 108. Perfectly conscious 
but irritable ; vomited while being taken to the ward. Tense hematoma — the 
size of a lemon, over the left half of the frontal bone; after very careful pal- 
pation it was decided that a depressed fracture of the underlying bone was 
undoubtedly present; apparent crepitus was also elicited at its posterior 
border. No bleeding from the nose, mouth or ears ; bilateral orbital ecehy- 
moses, but both mastoid areas were of normal appearance. Pupils slightly 
35 



546 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

enlarged but equal and of normal reaction to light. Reflexes : all depressed 
but equal ; no Babinski. Fundi negative. On account of the mild degree 
of shock, it was decided to postpone more careful examinations and the 
elevation or removal of the depressed area of the vault until the general 
condition of the patient was better. 

Treatment. — Routine shock measures and the expectant palliative 
method. Within 12 hours, child seemed almost well except for the tense 
swelling over the left half of the frontal bone ; as a depressed fracture of 
the underlying bone had appeared so evident, no X-ray picture was 
requested — a careless mistake and an inexcusable one in a hospital 
equipped properly. 

Operation (2 days after admission). — Exploratory incision of scalp 
(primary ether anesthesia) : small vertical incision of 4 cm. made over the 
hematoma ; much dark gelatinous blood evacuated, revealing an irregular 
tear of the f ronto-occipital aponeurosis ; underlying bone was normal and no 
fracture of the vault ascertained. Aponeurosis was sutured with interrupted 
catgut. Usual closure with 2 drains of rubber tissue inserted beneath scalp. 
Duration, 18 minutes. Lumbar puncture — clear cerebrospinal fluid under 
normal pressure (8 mm.). 

Post-operative Notes. — Uneventful recovery ; all sutures removed on the 
fifth day. 

Examination at discharge (8 days after scalp incision). — Temperature, 
98.6° ; pulse, 82 ; respiration, 26 ; blood-pressure, 112. No complaints except 
soreness at the site of former hematoma. Scalp wound healed perfectly. 
Ecchymoses of both orbits fading rapidly. Pupils equal and react normally. 
Reflexes negative. Fundi negative. 

Examination (April 26, 1917 — 23 months after injury) . — No complaints; 
"no hair along place of operation"; goes to kindergarten daily. Reflexes 
negative. Fundi negative. 

Last Report (February 28, 1919 — 45 months after injury). — No com- 
plaints; "bright girl in school." 

Remarks. — It was gross carelessness that X-ray pictures were not taken 
of the skull of this patient in several planes if necessary, so that this unfor- 
tunate mistake would have been avoided ; although the risk of an exploratory 
scalp incision is practically nil, yet when it can be avoided by careful ront- 
genograms, it should certainly be at least attempted. In all doubtful cases, 
however, an exploratory scalp incision is to be performed as being much the 
safer procedure than permitting the patient to undergo the great risk of 
future complications, and especially in children, such as emotional instability, 
epileptiform seizures, mental retardation, etc. 

Case 138. — Acute cranial injury simulating a depressed fracture of the 
vault. Exploratory incision of the scalp ; no depression ascertained. Excel- 
lent recovery. 

No. 21.— Randolph. Four years. White. U. S. 

Admitted August 1, 1913. Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Operation August 3, 1913 — 50 hours after injury. Exploratory 
scalp incision. 



IN NEWBORN BABIES AND CHILDREN 547 

Discharged August 15, 1915 — 12 days after scalp incision. 

Family history negative. 

Personal history negative. 

Present Illness, — While playing upon a fire-escape, child fell to the 
ground — a distance of twenty feet ; loss of consciousness for several minutes ; 
patient was carried to the hospital by a neighbor. 

Examination upon admission (15 minutes after injury). — Tempera- 
ture, 97.8°; pulse, 140; respiration, 34; blood-pressure, 96. Conscious but 
very stuporous; in severe shock. Over right parietal area was a boggy, 
doughy hematoma and ecchymosis, and upon palpation a distinct vertical 
line of fracture was apparent; marked tenderness along this area; at the 
lower portion over the right parietal crest the sensation of a depressed area 
of bone was obtained. No bleeding from nose, mouth or ears; no orbital 
or mastoid ecchymoses. No paralyses or impairments of sensation elicited. 
Pupils equally enlarged and react to light sluggishly. Reflexes all depressed 
but otherwise negative. Fundi negative. On account of the severe con- 
dition of shock, no prolonged examination was made. 

Treatment. — Vigorous shock measures instituted. Within six hours, the 
general condition of the patient had so improved that he was considered 
as being out of immediate danger. 

Examination (48 hours after injury). — Temperature, 99.4°; pulse, 90; 
respiration, 28 ; blood-pressure, 108. Conscious but rather drowsy. The 
hematoma over the right parietal area more tense but palpation can still 
elicit an apparent vertical fracture with depression of its lower portion; 
acute local tenderness persists. Hearing negative; otoscopic examination 
negative. Pupils equal and react normally. Reflexes — patellar active but 
equal ; no ankle clonus nor Babinski ; abdominal reflexes present and equal. 
Fundi — retinal veins slightly enlarged ; no obscuration of the details of either 
optic disk. Lumbar puncture — clear cerebrospinal fluid under normal pres- 
sure (approximately 8 mm.). No X-ray picture requested in the belief that 
the fracture and depression of the vault did not require confirmation (a 
mistaken opinion and especially in a hospital having all the modern facilities 
for accurate work). 

Treatment. — The patient no longer being in the condition of shock, an 
exploratory incision of the scalp overlying the depressed fracture of the 
right parietal bone was advised, both to elevate or remove the depressed 
bone and at the same time to drain the hematoma, and thus lessen the danger 
of the hematoma becoming infected with an extension of the infective process 
intracranially through the line of fracture. 

Operation (50 hours after injury). — Exploratory incision of scalp 
(primary anesthesia) : small vertical incision of 4 cm. over the right parietal 
crest and overlying the site of the supposed depressed area of bone. Upon 
retracting the scalp, the pericranium (fronto-occipital aponeurosis) was 
found to be torn vertically with its edges turned upward : no fracture of the 
underlying bone ascertained nor any depression. For fear that a depressed 
fracture of the inner table of the bone might be present, a small opening 
was made with the Doyen perforator and burr and enlarged with rongeurs 
to a diameter of 2 cm. ; no fracture or depression of the inner table observed 



548 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and the underlying dura was negative. Usual closure with. 2 drains of rubber 
tissue inserted. Duration, 25 minutes. 

Post -operative Notes. — No complications, so that the patient made an 
uneventful recovery. 

Examination at discharge (12 days after operation). — Temperature, 
98.8°; pulse, 86; respiration, 24; blood-pressure, 110. Operative wound 
healed per primam. Pupils negative. Reflexes negative. Fundi negative. 
No complaints and "I want to go home." 

Examination (September 20, 1915 — 23 months after injury). — No com- 
plaints. Slight pulsation palpable at site of removal of bone. Reflexes 
negative. Fundi negative. 

Last Examination (June 12, 1918 — 70 months after injury). — No com- 
plaints referable to the former cranial injury ; has been going to school daily 
and his reports are excellent, Reflexes negative. Fundi negative. 

Remarks.— The mistake illustrated in this case-history is a rather fre- 
quent one, unless X-ray pictures are taken as a routine procedure of all 
cranial injuries ; naturally, it would be advisable to perform an exploratory 
operation as in this patient, even in the absence of a depressed fracture 
of the vault, than to overlook a depressed area of the vault and in all doubt- 
ful patients an exploratory incision should be made; careful rontgeno- 
grams should always be taken when possible and thus obviate the necessity 
of an exploratory scalp incision in the absence of a bony depression. The 
danger of future complications is very great indeed if a depressed fracture 
of the vault is overlooked and not elevated or removed, and no patient 
should be permitted to run that risk without every facility of careful exam- 
ination and diagnosis having been utilized. 

Whenever a fracture of the vault underlying an extensive, tense hema- 
toma is ascertained, either by palpation or by rontgenograms, and there is a 
definite chance for the hematoma to become infected through the overlying 
bruised and contused skin, it is always wiser to incise and drain the 
hematoma through a small opening and through a normal portion of the 
skin, and thus lessen the great danger of an infective process extending 
through the line of fracture to produce a purulent meningitis with its great 
danger and many complications. 

Case 139. — Linear fractures of both tables of the vault underlying an 
extensive hematoma of the scalp ; no signs of an increased intracranial pres- 
sure. No operation except drainage of hematoma. Excellent recovery. 

No. 731.— Esther. Four years. White. U. S. 

Admitted November 24, 1917 — 6 days after cranial injury. Polyclinic 
Hospital. Referred by Doctor George W. Hawley. 

Operation November 26, 1917 — 2 days after admission. Drainage 
of hematoma. 

Discharged November 29, 1917 — 9 days after scalp incision. 

Family history negative. 

Personal history negative. 

Present Illness. — While at play, patient fell from a small go-cart, striking 
the right side of her head ; no loss of consciousness and no bleeding from the 
nose, mouth or ears; no apparent ill-effects from the injury and child ate 



IN NEWBORN BABIES AND CHILDREN 



549 



its regular supper. The next morning, a large hematoma of almost 3 inches 
in diameter was present over the right parietal area — the site of the ' ' bump ' ' ; 
very tense and did not fluctuate. During the next four days, the child 
seemed normal in every way, except for a slight drowsiness and the complaint 
of headache. No abnormal neurological signs of an intracranial lesion. 

Examination upon admission (6 days after injury). — Temperature, 
98.8° ; pulse, 80 ; respiration, 26 ; blood-pressure, 116. Conscious and appar- 
ently normal both mentally and physically. Tense hematoma over right 
parietal area — almost 3 inches in diameter. Careful bimanual examination 
revealed no fracture of the underlying and adjacent bone. Pupils equal and 
react normally. Reflexes — patellar present and equal ; no ankle clonus nor 
Babinski ; abdominal reflexes, 
present and equal. Fundi 

negative except for slight **N* 

dilatation of the retinal 
veins; no edematous blur- 
ring of the optic disks. Lum- 
bar puncture — slight blood- 
tinged cerebrospinal fluid 
under normal pressure (7 
mm.). X-ray (Doctor G. W. 
Welton) — "a horizontal lin- 
ear fracture of right parietal 
bone underlying the hema- 
toma of scalp" (Fig. 159). 

Treatment. — As the he- 
matoma was gradually en- 
larging and had become 
much more tense during the 
past 48 hours, and especially 
in the presence of an under- 
lying fracture of the vault 
but with no signs of an 
increased intracranial pres- 
sure, it was considered advis- 
able to drain the hematoma through a small scalp incision and thereby afford 
a safe means of drainage for the intracranial hemorrhage and excess cerebro- 
spinal fluid, but also to lessen the danger of the hematoma, becoming infected 
and thus the great risk of a later purulent meningitis. Accordingly, the 
entire right half of the head was closely shaved, iodine applied and a small 
scalp incision of one-eighth of an inch long, made at the lower edge of the 
hematoma; much dark blood (almost three ounces) with cerebrospinal fluid 
escaped, permitting the swelling to subside entirely; no drain inserted 
(for fear of increasing the danger of infection). Otherwise, the routine 
expectant palliative treatment. 

Examination (1 day after admission ).— Temperature, 9S.6° ; pulse, S2 : 
respiration, 24; blood-pressure, 114. Mother states that the child "is show- 
ing more interest in things"; not so drowsy and "wishes to play with her 
doll." Pupils equal and react normally. Reflexes negative. Fundi nega- 




Fig. 159. — Extensive linear fracture of right parietal bone 
concealed by an overlying hematoma in a patient who made 
an excellent recovery with the expectant palliative treatment 
and the drainage of the hematoma. The importance of ront- 
genograms of all patients having head injuries is obvious 
for fear of later complications. 



5 so DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tive, and the retinal veins are now of normal size. Upon removing the head 
bandage, the hematoma had refilled but not tensely, and upon inserting 
a probe into the small scalp incision, about one ounce of dark syrupy blood 
and cerebrospinal fluid escaped so that the swelling of the hematoma again 
disappeared. This same treatment of drainage was used the following day 
and a smaller amount of dark blood and cerebrospinal fluid permitted to 
escape, and upon the application of a firm head bandage, it was ascertained 
the next day that the hematoma did not refill. 

Examination at discharge (5 days after admission). — Temperature, 
98.6°; pulse, 82; respiration, 26; blood-pressure, 116. No complaints and 
apparently normal in every way. Site of former hematoma flat and the 
overlying scalp is now adjacent to the vault ; small scalp incision has healed 
per primam. Pupils negative. Reflexes negative. Fundi negative. 

Examination (May 20, 1918 — 6 months after injury). — No complaints; 
' ' child is as well as ever. ' ' Reflexes negative. Fundi negative. 

Last Report (March 18, 1919 — 16 months after injury). — (Letter from 
mother) : "Esther is in the best of health and seems normal in every way/' 

Remarks. — If an X-ray picture had not been obtained in this patient, it is 
probable that the condition would have been considered merely as a "bump" 
upon the head with a resulting hematoma of large persistent character ; it is 
also very probable that, if no complications of infection of the hematoma 
occurred, that this patient would have made an excellent recovery, even if 
the hematoma had not been drained through the scalp incision. However, 
the danger of infection of the hematoma in these patients is a definite factor 
and a distinct danger, and if it had occurred in the presence of the under- 
lying fracture of the vault and the torn dura (since cerebrospinal fluid 
was present in the discharge), the result would undoubtedly have been 
a fatal one. If the roentgenogram had not disclosed a fracture of the under- 
lying vault, then an operative drainage of the hematoma, either by means 
of a small scalp incision or aspirating needle, would have been optional 
and, unless the hematoma persisted for a number of days and was even en- 
larging on account of the tenseness, it is usually not necessary to drain it. 

The presence of the fracture of the vault in this patient, and especially 
associated with a tear of the underlying dura, made it possible for the sub- 
dural hemorrhage and the excess cerebrospinal fluid to escape extracranially 
into the subcutaneous tissues of the scalp and thus, even at the risk of an 
infection (and this is a definite factor in patients where the overlying scalp is 
lacerated and contused), this patient really "decompressed" herself so that 
an increased intracranial pressure did not appear to a degree higher than 
was exhibited by the slight dilatation of the retinal veins, and the spinal 
mercurial manometer did not register a pressure above the normal (and it 
is the most accurate test). If this fracture of the vault with the laceration 
of the adjacent dura had not occurred, it is very probable that this amount 
of subdural hemorrhage and excess cerebrospinal fluid would have produced 
a marked increase of the intracranial pressure, and it is possible that the 
operation of subtemporal decompression and drainage would have been 
advisable, if the expectant palliative treatment was not sufficient to lower 
this intracranial pressure by the natural means of absorption. 



IN NEWBORN BABIES AND CHILDREN 



55i 



Case 140. — Acute mild brain injury associated with an extensive linear 
fracture of the vault ; no signs of an increased intracranial pressure. No 
operation. Excellent recovery. 

No. 552. — Constance. Ten years. White. School. U. S. 

Admitted April 6, 1916. Polyclinic Hospital. Referred by Doctor 
J. H. Fuchsius, New Rochelle. 

Discharged April 10, 1916 — 4 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the road, patient was knocked down by 
a taxicab ; unconscious for several minutes. Upon recovery from the severe 
shock, the child was brought to the hospital in an automobile. 

Examination upon admission (3 hours after injury). — Temperature, 
98.8° ; pulse, 92 ; respiration, 
26 ; blood-pressure, 106. Con- 
scious ; in mild degree of 
shock. Large boggy hema- 
toma over the entire occipital 
area of the vault, and espe- 
cially over the left side ; the 
overlying scalp was not 
b r u i s e d or lacerated. No 
bleeding from nose, mouth or 
ears; both mastoid areas ec- 
chymotic — left more than 
right. Otoscopie examination 
negative. Careful bimanual 
examination negative, except 
for tenderness in the left 
mastoid and left half of the 
occipital bone. No paralysis 
nor impairment of sensation 
elicited. Pupils equal and 
react normally. Reflexes — patellar possibly depressed but equal ; no ankle 
clonus nor Babinski; abdominal reflexes sluggish but equal. Fundi nega- 
tive. Lumbar puncture — clear cerebrospinal fluid under normal pressure 
(8 mm.). X-ray (Doctor W. H. Stewart) — "an extensive linear fracture 
beginning in the posterior occipital prominence at the inferior portion and 
extending upward and forward across the left lambdoidal suture and ending 
in the posterior portion of the left parietal bone" (Fig. 160). 

Treatment. — Routine treatment for the mild condition of shock asso- 
cated with the usual expectant palliative method of treatment. The patient 
made an excellent recovery in that 6 hours later, the temperature was 99.2°, 
pulse 82, respiration 24, while the blood-pressure had ascended to 114. The 
hematoma over the back of the head did not become tense and the overlying 
scalp remained in an excellent condition. No signs of an increased intra- 
cranial pressure elicitable. 

Examination at discharge (4 days after admission). — Temperature. 




Fig. 160. — Extensive linear fracture of the posterior portion 
of left vault, in a patient having no signs of an increased 
intracranial pressure. Excellent recovery with the expectant 
palliative treatment. 



552 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

98.6° ; pulse, 80 ; respiration, 24 ; blood-pressure, 116. No complaints except 
for soreness over the back of the head, and especially over the left side; 
otherwise well. Hearing normal. Pupils negative. Reflexes negative. 
Fundi negative. 

Examination (Sept. 4, 1917 — 17 months after injury). — No complaints. 
School reports of teacher excellent. Reflexes negative. Fundi negative. 

Last Report (April 24, 1919 — 36 months after injury). — Xo complaints; 
perfectly well. 

Remarks. — Although the fracture of the vault was situated in a danger- 
ous area, yet no complication from the underlying sinuses resulted. The 
line of fracture undoubtedly permitted the escape of intracranial blood and 
possibly cerebrospinal fluid to drain into the tissues of the overlying scalp 
and thus permitting a normal intracranial pressure and insuring an excel- 
lent recovery. If the skin of the adjacent scalp had been bruised and its 
resistance lowered, then the danger of an infective process extending 
to the hematoma, and even intracranially, would have been a most 
serious complication. 

It is rather surprising that the line of fracture in this patient did not 
extend into the left middle ear, since this complication usually occurs 
when the mastoid portion of either temporal bone is fractured ; the otoscopic 
examination is conclusive and not merely a bleeding from the ear, uuless 
mixed with cerebrospinal fluid. 

Case 141. — Acute brain injury associated with a fracture of the vault 
and with a small amount of subdural hemorrhage ; mild signs of an increased 
intracranial pressure. Xo operation. Excellent recovery. 

Xo. 1017.— Mary. Six years. \Yhite. School. U. S. 

Admitted August 30, 1918. Polyclinic Hospital. Referred by Doctor 
J. A. Bodine. 

Discharged September 13, 1918 — 14 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a fire-escape, child fell to the 
ground below — a distance of 20 feet ; loss of consciousness for several min- 
utes ; brought to the hospital by the mother. 

Examination upon admission (2 hours after injury)- — Temperature, 
97.2°; pulse, 100; respiration, 30; blood-pressure, 106. Rather drowsy and 
in moderate shock. Extensive hematoma over the left parietal area; the 
overlying scalp is not damaged. No bleeding from nose, mouth or ears; 
no orbital or mastoid ecchymoses. No paralyses ascertained. Pupils — 
slightly enlarged but equal and of normal reaction to light. Reflexes: all 
depressed but equal ; no Babinski. Fundi negative. 

Treatment. — Vigorous shock measures instituted — especially heated 
blankets and hot water bottles, rectal enemata of hot black coffee and warm 
normal saline solution. The patient reacted very quickly to these measures, 
so that the clinical picture changed rapidly from one of shock to that of 
a definite intracranial lesion of mild degree. 

Examination (3 hours after admission — 5 hours after injury). — Tem- 
perature, 100.6° ; pulse, 76 ; respiration, 26 ; blood-pressure, 112. Child 



IN NEWBORN BABIES AND CHILDREN 



553 



is very drowsy — cries upon being aroused, and then becomes stuporous almost 
immediately. Hematoma over the left parietal area is not enlarging or 
becoming more tense. Left orbital ecchymosis; no mastoid discoloration. 
Pupils equal and react normally. Reflexes — patellar exaggerated but equal ; 
double ankle clonus and double Babinski; abdominal reflexes depressed — 
left can scarcely be elicited. Fundi — retinal veins slightly enlarged ; nasal 
margins of both optic disks blurred by edema. Lumbar puncture — bloody 
cerebrospinal fluid under a slightly increased pressure (8 mm.). X-ray 
(Doctor G. W. Welton) — "fissured oblique linear fracture through the 
upper portion of the left frontal bone backward into the left parietal bone ; 
no depression" (Fig. 161). 

Treatment. — Expectant palliative treatment continued, assisted by lum- 
bar puncture with drainage of 15 c.c. of the bloody cerebrospinal fluid upon 
the following two days, when 
the pressure was only 7 mm. 
The patient made an excel- 
lent recovery in that after 
30 hours the stupor dis- 
appeared, normal conscious- 
ness returned, and the 
positive signs of an intra- 
cranial lesion quickly faded 
away. 

E x a m i n at io n at dis- 
charge ( 14 days after admis- 
sion). — Temperature, 98.6°; 
pulse, 80; respiration, 24; 
blood-pressure, 114. No 
complaints except for a 
general soreness of the 
left side of head ; scalp 
slightly boggy over that 
area. Hearing negative ; 
otoscopic examination negative. Pupils equal and react normally. Reflexes : 
active but otherwise negative ; no ankle clonus or Babinski ; abdominal re- 
flexes possibly depressed but equal. Fundi — retinal veins slightly enlarged ; 
details of both optic disks clear. 

Treatment. — General hygienic rules; parents advised not to send child 
to school for one year. 

Last Examination (May 18, 1919 — 9 months after injury ). — Xo com- 
plaints. Reflexes negative. Fundi negative. 

Remarks. — The rapid recovery from the initial shock by this patient is 
characteristic of children, and then the signs of an intracranial lesion 
can be easily and safely demonstrated, but no attempt to examine the 
patient carefully should be made in the presence of a severe degree of shock 
which would be prolonged, if not increased. 

Lumbar puncture drainage of the free blood in the cerebrospinal fluid 
in the absence of high pressure is an excellent therapeutic measure: also if 




Fig. 161. — Extensive linear fracture of anterior portion of 
left vault, in a patient having a slight increase of the intra- 
cranial pressure due to a subdural hemorrhage. Excellent 
recovery with the expectant palliative treatment. 



554 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the pressure is only moderately increased — not over 15 mm. — then this 
method of lessening the exeess cerebrospinal fluid can be used, especially in 
children, and thus the operation of cranial decompression and drainage be 
avoided ; in these selected patients, this method of spinal drainage may be 
•considered a part of the expectant palliative treatment. 

The presence of a linear fracture of the vault underlying the hematoma 
would not have been recognized had a positive rontgenogram not been 
obtained, and yet the treatment remains the same — fracture or no fracture. 
If a depression had been demonstrated, naturally its elevation or removal 
would have been advisable; also if the overlying scalp had been badly 
contused and infected, then the aspiration of a tense hematoma through a 
clean area of the scalp or even a small drainage incision would have been 
urged, in order to lessen the great danger of the hematoma becoming infected 
and thus the extension of the infective process through the linear fracture 
intracranially — the history of occasional cases of purulent meningitis 
following cranial injuries. 

Case 142. — Acute severe cranial injury associated with a fracture of 
the base of the skull, but with no increase of the intracranial pressure. No 
operation. Excellent recovery. 

No. 83. — George. Nine years. White. School. U. S. 

Admitted May 14, 1914. Polyclinic Hospital. Referred by Doctor 
R. E. Brennan. 

Discharged May 18, 1914 — 4 clays after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing Broadway, patient was knocked down 
by an automobile ; unconscious for several minutes ; brought to the hospital 
in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98° ; pulse, 120 ; respiration, 26 ; blood-pressure, 106. Rather stuporous 
and drowsy but upon being aroused, the patient answers questions clearly ; 
severe degree of shock; multiple contusions about the head, especially 
over the right parietal area, which is boggy and tender. Profuse bleeding 
from nose and left ear ; small amount of cerebrospinal fluid observed in the 
aural discharge; otoscopic examination of right ear discloses the right 
tympanic membrane to be bulging and bluish. Double orbital and mastoid 
ecchymoses (Figs. 162 and 163). Pupils — slightly enlarged but equal and 
react to light sluggishly. Reflexes: all depressed but otherwise negative; 
no Babinski. Fundi negative. For fear of increasing the condition of shock, 
no further examination was made at this time. 

Treatment. — Vigorous shock measures instituted and the usual routine 
expectant palliative treatment. Within 6 hours, the condition of the patient 
had so improved that the temperature was now 99°, pulse 96, respiration 
24 and the blood-pressure 118 ; the bleeding from both the nose and the 
left ear had ceased ; the pupils were negative, while the reflexes were active 
but otherwise negative; ophthalmoscopic examination disclosed a possible 
enlargement of the retinal veins, but no obscuration of the details of either 
optic disk ; a lumbar puncture now performed permitted clear cerebrospinal 



IN NEWBORN BABIES AND CHILDREN 



555 



fluid to escape under normal pressure (approximately 8 mm. ) . X-ray report 
(Doctor A. J. Quimby) — "no fracture of the skull observed." 

Treatment. — The expectant palliative treatment was continued and as 
the patient did not feel sick in any way and had no complaints, he 
insisted with the aid of his parents upon being discharged — 87 hours after 
the injury. 

Examination at discharge (4 days after admission). — Temperature, 
98.8° ; pulse, 80 ; respiration, 24 ; blood-pressure, 118. No complaints, except 
for slight dull headache and "I'm going home and away from this joint." 
Both orbital and mastoid ecchymoses less extensive. Hearing of both ears 
impaired — left more than right, and bone conduction was greater than air 
conduction in both ears; otoscopic examination reveals a small laceration 




Fig. 162. — Bilateral orbital ecchymosis with right and left subconjunctival hemorrhages in a patient 
having a fracture of the base of the skull but no increase of the intracranial pressure. Excellent recovery 
with the expectant palliative treatment. 

of the upper posterior portion of the left tympanic membrane ; right tym- 
panic membrane less bulging but it is still bluish. Pupils equal and react 
normally. Reflexes active but otherwise negative. Fundi — retinal veins 
possibly enlarged but otherwise negative. 

Treatment. — Parents cautioned to keep the patient in bed for at least 
a week and under the routine expectant palliative treatment ; not to attempt 
to cleanse the ears or the nose ; light non-stimulating diet ; daily catharsis. 
Parents were obliged to sign the hospital blank "discharged at own request. " 

Examination (September 10, 1917 — 40 months after injury"). — No com- 
plaints referable to the former head injury; "stands well in school"; no 
headache. Slight impairment of hearing of right ear but left ear is normal ; 
otoscopic examination discloses a normal left tympanic membrane but a 
slightly thickened and retracted right tympanic membrane ; bone conduc- 
tion equals air conduction in right ear, whereas air conduction is greater 



556 DIAGNOSIS AND TREATMENT OF^BRAIN INJURIES 



than bone conduction in left ear (the normal condition). Reflexes negative. 
Fundi negative. 

Last Examination (April 16, 1919 — 73 months after injury). — No com- 
plaints. Father states he is " just as well as if the bump on the head had not 
happened; he certainly fooled the doctors." Hearing the same as at pre- 
ceding examination, the hearing of the right ear being slightly less acute than 
that of the left ear. Reflexes negative. Fundi negative. 

Remarks. — The comparative unimportance of the fracture of the skull 
in these patients having cranial injuries, and even of the base of the skull, 
is well illustrated by this patient; it is undoubtedly of rather frequent 

occurrence to have a 
fracture of the skull 
present — more often of 
the vault but also of the 
base, and yet there are 
no signs of a definite 
intracranial lesion re- 
sulting from the cranial 
injury, and these latent 
fractures of the skull are 
the main pathological 
condition to be ascer- 
tained — usually by the 
X-ray in fractures of the 
vault or by the discharge 
of cerebrospinal fluid, 
occasionally rontgeno- 
grams, and also by the 
otoscope in fractures of 
the base of the skull. 
The danger of an infec- 
tive process extending 
through the line of frac- 
ture, and particularly in 
fractures of the base, is a definite risk, and yet it is a slight one, unless med- 
dlesome procedures such as the irrigation and swabbing out of the ears and 
nose should be attempted ; in fractures of the vault, and especially in com- 
pound fractures or in some cases of tense hematomata with severe contusion 
of the overlying scalp — in these patients a rigid asepsis is essential and the 
drainage of the hematomata in selected cases. 

The rapid recovery and the uneventful convalescence of this patient is the 
rule in children rather than the exception, in almost three-fourths of the 
patients, and it also occurs in adults in almost two-thirds of the patients ; 
the recovery is not so rapid in the latter patients but it is usually an unevent- 
ful one. These excellent recoveries are due not to the presence or absence 
of a fracture of the skull, but to the presence or absence of a marked increase 
of the intracranial pressure and whether the intracranial condition is one of 




Fig. 163. — Showing right mastoid ecchymosis in a patient having 
a fracture of the base of the skull— the left tympanic membrane 
torn and permitting the escape of cerebrospinal fluid, whereas the 
right tympanic membrane remained intact but bluish and bulging. 
Excellent recovery with the expectant palliative treatment. 



IN NEWBORN BABIES AND CHILDREN 557 

hemorrhage or of edema; in either case, if the increased intracranial pres- 
sure is a high one, then it is essential and safer to lessen it by the operation 
of decompression and drainage, but if the increased intracranial pressure is 
normal or only slightly above normal, then the expectant palliative method 
of treatment is entirely satisfactory ; repeated lumbar punctures and drain- 
age can be used for selected patients in whom the increased intracranial 
pressure is a mild one. The presence or absence of a fracture of the skull — 
unless it is a depressed fracture of the vault — is of little value and of little 
importance in the treatment of these patients. 

Case 143. — Acute severe cranial injury associated with multiple com- 
pound linear fractures of the vault; streptococcic infection of the cranial 
wound with symptoms and signs of meningeal irritation. No operation; 
anti-streptococcic serum administered. Excellent result. 

No. 73. — Lewis. Six years. White. School. U. S. 

Admitted May 4, 1914, Polyclinic Hospital. Referred by Doctor John 
A. Wyeth. 

Discharged May 14, 1914 — 10 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street, patient was struck upon the 
forehead by a broom-handle, which had fallen from a distance of 4 stories ; 
momentarily stunned, but apparently no loss of consciousness; child was 
able to walk to the hospital. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98.6° ; pulse, 90 ; respiration, 28 ; blood-pressure, 106. Conscious and 
in little or no shock; ''somebody hit me over the head." Just within the 
hairline of the median portion of the frontal bone was a lacerated wound 
of the scalp, one and a half inches in length and extending over the longitu- 
dinal sinus ; after shaving the surrounding area and carefully cleansing the 
wound with soap and water, gentle probing revealed 3 distinct lines of 
fracture extending from the underlying area of bone ; no depression of the 
bone ascertained ; wound carefully swabbed with iodine solution and sterile 
dressing applied. No paralyses nor sensory impairments ascertained. No 
bleeding from nose, mouth or ears; no orbital nor mastoid ecchymoses. 
Hearing negative ; otoscopic examination negative. Pupils equal and react 
to light normally. Reflexes negative. Fundi negative. Lumbar puncture — 
clear cerebrospinal fluid under normal pressure (approximately 7 mm.). 
X-ray (Doctor A. J. Quimby) — "multiple lines of fracture extend irregu- 
larly for several inches through the frontal and parietal bones" (Fig. 164^ . 

Treatment. — The expectant palliative treatment in addition to the local 
treatment of the wound which was again dressed 8 hours later ; 3 silk sutures 
inserted loosely and the 2 drains of rubber tissue replaced. Patient showed 
no ill-effects of the cranial injury and was apparently making an excellent 
recovery, when 30 hours later the child vomited, had a chill, and it was 
ascertained that the temperature had quickly ascended to 104.6°, the pulse 
to 96, the respiration to 30, and the blood-pressure to 114. There was 
definite rigidity of the neck, a positive Kernig test, and the child had become 
rather drowsy and stuporous; there was no change in the reflexes, but 



558 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



the ophthalmoscope disclosed slightly enlarged retinal veins, while the 
lumbar puncture removed clear cerebrospinal fluid under a slightly increased 
pressure (approximately 10 mm.) ; 16 c.c. were withdrawn; the laboratory 
report (Doctor Jeffries) — "14 cells per cubic mm. but no bacteria found." 
Treatment. — Upon dressing the scalp wound overlying the linear frac- 
tures of the frontal bone, several drops of a thin seropurulent secretion were 
obtained and the report of the culture was "pure streptococci— short- 
chained." Wound was opened and cleansed again with iodine, lightly 
packed with sterile gauze and a wet bichloride (1-5000) dressing applied; a 
large head dressing kept saturated in the bichloride solution. Anti-strepto- 
coccic serum was immediately administered in its usual dose of 10 c.c. and 
within one-half hour, the temperature began to drop and 2 hours later 
the temperature was 102°, and the following day it was down to normal; 

another lumbar puncture- 
was now performed and clear 
cerebrospinal fluid was 
found to be under normal 
pressure (approximately 8 
mm.), while the laboratory 
report was only 7 cells per 
c.mm. The rigidity of the 
neck and the positive Kernig 
were not present, and the 
child became bright mentally 
and did not complain even 
of headache. The general 
and local condition of the 
child rapidly improved so 
that the convalescence was 
uneventful. 

Examination at discharge 
(10 days after injury). — 
Temperature, 98.6° ; pulse, 
84; respiration, 24; blood- 
pressure, 114. No complaints ; slight soreness and tenderness over the area 
of the former scalp wound which has now healed perfectly. Pupils equal 
and react to light normally. Reflexes negative. Fundi negative. 

Examination (April 20, 1916 — 23 months after injury). — No complaints 
referable to the former head injury ; is doing well in school. Reflexes nega- 
tive. Fundi negative. 

Last Report (June 12, 1919 — 61 months after injury). — Mother states 
that child does not show any ill effects of the former injury; "no different 
from other boys." 

Remarks. — The danger of a purulent meningitis resulting from the 
scalp infection in this patient, and especially in the presence of the multiple 
fractures of the underlying bone, was very great indeed ; the successful 
cleansing of the wound itself, however, together with the early administration 
of the antistreptococcic serum undoubtedly aided the resistance of the tis- 




Fig. 164. — Extensive multiple linear compound fractures 
of frontal bone and right parietal bone, in a patient developing 
signs of meningeal irritation; no increased intracranial pressure. 
Excellent recovery with the expectant palliative treatment. 



IN NEWBORN BABIES AND CHILDREN 559 

sues to the infection, so that the signs of meningeal irritation rapidly sub- 
sided and an excellent result was obtained. It is rather puzzling that a 
persistent discharge of the purulent secretion did not result from the 
infection of the bone itself and especially at the site of the fractures ; 
apparently the infection had not become sufficiently established before 
the iodine was applied. 

If there had not been a rapid subsidence of the symptoms and signs of 
the meningeal irritation, then it would have been advisable to have per- 
formed as early as possible a subtemporal decompression and drainage and 
the local operation of the removal of the fractured area of bone underlying 
the infected scalp wound, and in this manner not only would the local source 
of the infection be removed, but the decompression operation and drainage 
would have lowered the increasing intracranial pressure and have thus per- 
mitted the brain and its meninges to resist the infection much more suc- 
cessfully. In this patient, however, the temperature descended so quickly 
following the opening and cleansing of the wound and also the disappear- 
ance of the rigidity of the neck and the positive Kernig tests occurred so 
quickly, together with a lowering of the cell count of the cerebrospinal fluid, 
that naturally no cranial operation was considered necessary. 

If the cerebrospinal fluid at lumbar puncture in this patient had been 
cloudy and yet no bacteria present, then the cranial operations would have 
been advisable as giving the patient a definite chance of recovery, but if 
bacteria had been found in the cerebrospinal fluid, then the condition would 
not have been a localized meningitis as in the former case, but a diffuse 
one, and therefore beyond the realm of surgery from the standpoint of an 
operation being of any real benefit to the patient. 

If the dura underlying these linear fractures of the frontal bone had 
been torn in this patient, it is very probable that the infection of the scalp 
would have extended intracranially and therefore a purulent meningitis 
would undoubtedly have occurred. The importance of cleansing all scalp 
wounds carefully, together with a shaving of the surrounding scalp, is 
self-evident; if depressed fractures of the vault are excluded, this case- 
history is another illustration of the comparative unimportance of the 
fracture of the skull in these patients having cranial injuries, as compared 
with the possibility of severe intracranial lesions. This patient was able 
to walk to the hospital himself and yet there were present 3 linear fractures 
of the skull ; this is not unusual in children and merely indicates the neces- 
sity of examining all of these patients most carefully for fear that the 
cranial condition is a more severe one than is indicated from a superficial 
examination alone, and therefore the proper treatment can be insti- 
tuted early. 

B. Acute train injuries associated with a mild increase of the intracranial 
pressure. Repeated lumbar punctures and drainage. Excellent recovery. 

Case 144. — Acute severe brain injury associated with a subdural hemor- 
rhage and with a mild increase of the intracranial pressure: several Jack- 
sonian convulsive seizures. Repeated lumbar punctures and drainage. Ex- 
cellent recovery. 

No. 84.— James. Five years. Black. U. S. 



5 6o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Admitted August 6, 1914, Polyclinic Hospital. Referred by Doctor 
A. S. Morrow. 

Discharged September 6, 1914 — 30 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing on the fourth floor of a hallway, child 
fell through the areaway down to the first floor upon the cement pavement ; 
immediate loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 99° ; pulse, 120; respiration, 30; blood-pressure, 102. Semiconscious; 
mild condition of shock. Very restless and moans continuously. Over left 
parietal area is a diffuse hematoma — not tense and not tender. Profuse 
bleeding from left ear ; left mastoid ecchymosis. Pupils, dilated and react 
to light sluggishly. (At this period of the examination, a convulsive seizure 
of the right arm and the right leg occurred with occasional twitches of 
right side of the face and continued for 3 minutes; no apparent loss of 
consciousness, no biting of the tongue nor involuntary micturition; left 
side of the body not involved. ) Reflexes : patellar — both exaggerated, right 
more than left ; no ankle clonus but right Babinski ; right abdominal reflexes 
absent. Fundi — retinal veins enlarged ; nasal margins of both optic disks 
slightly blurred by edema. Lumbar puncture — bloody cerebrospinal fluid 
under slightly increased pressure (approximately 10 mm.). 

Treatment. — It was decided to treat the child by the expectant palliative 
method combined with repeated lumbar punctures and drainage in the hope 
that this method would be sufficient ; naturally, if the signs of an increasing 
intracranial pressure occurred and if the right Jacksonian convulsions should 
persist, then a left subtemporal decompression and drainage would be the 
safer procedure. Two hours after admission, another convulsive seizure 
of the right side of the body occurred, but with no loss of consciousness; 
occasional convulsive twitchings of the right arm and of the right leg per- 
sisted during the following hour and then ceased. A daily lumbar puncture 
with removal of 15 c.c. of bloody cerebrospinal fluid 'was performed upon 
5 consecutive days and then upon every other day for 4 times ; it was very 
impressive to note the improved condition of the patient following each 
lumbar puncture in that his general condition became better, the restless- 
ness subsided, and if stuporous and drowsy then he became aroused suffi- 
ciently so that he was able to answer questions intelligently, became inter- 
ested in his surroundings, etc. ; this improved condition, however, rarely 
continued for more than 8 hours after each lumbar puncture until the 
fifth day after admission, when it was possible to perform the lumbar punc- 
ture and drainage every two days and yet obtain a marked improvement ; the 
cerebrospinal fluid became less blood-tinged and finally straw-colored, while 
the pressure of approximately 12 mm. at the second lumbar puncture grad- 
ually decreased, until it was only approximately 7 mm. at the ninth lumbar 
puncture on the thirteenth day after the injury. During this period from 
the second to the fifth day after admission, the temperature became as high 
as 103° and the pulse 120 and over, while the right arm and right leg were 
definitely weaker than the left arm and left leg; the right Babinski per- 



IN NEWBORN BABIES AND CHILDREN 561 

sisted, and yet at no time did the signs of a high intracranial pressure 
appear. This right hemiparesis gradually disappeared within a week and 
the child made an uneventful recovery. 

Examination at discharge (30 days after injury). — Temperature, 
98.6°; pulse, 84; respiration, 26; blood-pressure, 112. No complaints other 
than a soreness over the left half of vault; patient says: "I am all right." 
Hematoma over left parietal area has been absorbed. No weakness of right 
arm or right leg can be elicited by special tests. Impairment of hearing of 
left ear ; bone conduction is greater than air conduction ; otoscopic examina- 
tion reveals a small laceration in the posterior half of the left tympanic 
membrane. Pupils equal and react normally. Reflexes — patellar active, 
right possibly more than left ; no ankle clonus and no Babinski, but there 
is no plantar flexion to be obtained on right foot ; abdominal reflexes both 
depressed, right possibly less active than left. Fundi — retinal veins slightly 
enlarged; details of both optic disks clear. X-ray report (Doctor A. J. 
Quimby) — "no fracture of the skull observed." 

Examination (January 8, 1917 — 29 months after injury). — No com- 
plaints. Goes to school daily; is not considered a "nervous" child; has 
not had a convulsion since the day of the injury. Hearing of left ear normal ; 
otoscopic examination negative. Reflexes rather active but otherwise nega- 
tive. Fundi negative. 

Last Examination (May 24, 1919 — 69 months after injury). — No com- 
plaints ; possibly more irritable than the other children ; does well in school. 
Reflexes possibly increased but otherwise negative. Fundi negative. 

Remarks. — It is fortunate that such a good result was obtained in this 
patient, and yet a longer period of time must elapse before it can be stated 
with any degree of certainty that a normal patient has been obtained ; the 
great danger of convulsive seizures later in life and an emotional instability, 
with and without a mental retardation, must always be considered. If such 
a patient should be examined now in the acute stage following the injury, I 
feel that a left subtemporal decompression and drainage would offer the 
patient not only a greater chance of recovery of life but also of future nor- 
mality, and it is my opinion that even though an apparently good result was 
obtained in this patient by the expectant palliative treatment and the spinal 
drainage by repeated lumbar punctures, yet the patient underwent a much 
greater risk — both in the immediate results and in the remote effects of the 
injury — than if an early left subtemporal decompression and drainage had 
been performed as soon as the initial shock had subsided — that is, in this 
patient within 8 hours after the injury. The localized Jacksonian convul- 
sions of the right arm and right leg and then the subsequent weakness of 
the right side of the body which persisted for several days and associated 
with bloody cerebrospinal fluid — these signs indicated a localized lesion of 
the left cerebral cortex — most probably a supracortical hemorrhage or merely 
a localized cortical edema but of sufficient amount to cause this impair- 
ment; the repeated lumbar punctures and drainage were sufficient to relievo 
the general intracranial pressure and thereby overcome the local effects of 
the supracortical hemorrhage or cortical edema, but whether this nun hod 
of drainage was sufficient to remove the lesion, so that there will be no 
36 



562 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

remote signs of its presence in the form of cortical adhesions, a partial block- 
age of the cerebrospinal fluid so> that a mild condition of external hydro- 
cephalus will result in the form of a mild degree of - ' wet, ' ' edematous brain 
— these considerations can only be accurately judged by the later condition 
of this patient as revealed by future examinations. In the present develop- 
ment of the operative technic of cranial operations, and particularly of 
subtemporal decompressions and drainage, the risk is such a slight one that 
in all doubtful cases, such as this one, the operation should now be advised 
rather than the patient be permitted to risk such serious future complications. 

Case 145. — Acute severe brain injury not associated with a fracture of 
the skull nor with a marked increase of the intracranial pressure ; localized 
Jacksonian convulsions for 8 hours after the injury. No operation; re- 
peated lumbar punctures and drainage. Excellent recovery. 

No. 88.— William. Eight years. White. School. U. S. 

Admitted August 21, 1914. Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Discharged (at own risk) August 26, 1914 — 5 days after injury. 

Family history negative. 

Personal History. — Four years ago, patient fell from a one-story window, 
striking his head upon the ground ; loss of consciousness for one hour ; no 
bleeding from nose, mouth or ears; remained at home in bed for ten days 
and since then has been perfectly well ; no convulsive seizures at any time. 

Present Illness. — While playing baseball in the street, patient was 
knocked down by an automobile ; unconscious for several minutes ; brought 
to the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 99° ; pulse, 120; respiration, 24; blood-pressure, 114. Semiconscious; 
in practically no shock; answers questions when aroused and he then com- 
plains of severe headache. Contusion and hematoma of the right parietal 
area; definite tenderness. No bleeding from the nose, mouth or ears; no 
orbital or mastoid ecchymoses. No paralyses elicited but the left arm 
and left leg are not so relaxed asl the right arm and right leg. (At this 
stage of the examination, the left leg and the left arm of the patient began 
to twitch and to shake spasmodically — there being no tonic spasm but fre- 
quently repeated clonic contractions ; left side of face not involved ; appar- 
ently no loss of consciousness. This localized convulsive seizure continued 
for over five minutes, did not become general and gradually ceased — the 
contractions of the left leg being the last to disappear; no biting of the 
tongue nor involuntary micturition or defecation occurred.) Pupils: before 
the convulsion, the pupils were equally enlarged but with normal reaction 
to light, whereas after the convulsive seizure, they became equally con- 
tracted and it was difficult to elicit any reaction to light. (Child had become 
very restless — continually turning and twisting in bed and requiring re- 
straint.) Reflexes: patellar exaggerated, left more than right; exhaustible 
left ankle clonus and left Babinski ; abdominal reflexes — left less active than 
right. Fundi negative. Lumbar puncture — clear cerebrospinal fluid under 
slightly increased pressure (approximately 10 mm.) ; 12 c.c. slowly removed 
as a therapeutic measure of drainage to lessen the acute cerebral edema 



IN NEWBORN BABIES AND CHILDREN 563 

(excess cerebrospinal fluid "water-logging" the cerebral tissues entirely or 
only in areas). X-ray (Doctor A. J. Quimby) — "no fracture of the 
skull observed." 

Treatment. — Expectant palliative method assisted by repeated daily lum- 
bar punctures for 3 days in order to drain any excess cerebrospinal fluid 
or cerebral edema. Forty minutes after the first convulsion, a second simi- 
lar convulsive seizure occurred and again lasted almost 5 minutes; no 
loss of consciousness; the pupils remained equally contracted while the 
reflexes persisted in being exaggerated upon the left side and associated 
with a left Babinski ; the retinal veins, however, became slightly enlarged, 
but no edematous obscuration of the details of either optic disk appeared. 
Two hours after admission, a second lumbar puncture was performed and 
16 c.c. of clear cerebrospinal fluid under a pressure of approximately 10 mm. 
were carefully removed, until the pressure was only approximately 8 mm. 
A third convulsive seizure of the left leg and of the left arm occurred 5 
hours after admission, but it was much less severe than the preceding ones 
and continued for only one-half minute; the neurological examination 
remained practically the same as before, while a third lumbar puncture 
removed 14 c.c. of clear cerebrospinal fluid under a slightly increased pres- 
sure of approximately 9 mm., and at the end of the drainage the pressure 
was approximately 7 mm. No further convulsive seizures occurred ; the left 
arm and left leg were possibly slightly weaker than the right arm and right 
leg during the preceding examinations, but the difference was so slight that it 
could not be ascertained with certainty — the patient being right-handed 
and naturally stronger on the right side. 

Examination (29 hours after admission). — Temperature, 99.4°; pulse, 
94; respiration, 22; blood-pressure, 116. Rather drowsy but he is much 
brighter and answers questions easily and clearly. Hematoma over the 
right parietal bone remains boggy and not tense. No impairment of hearing ; 
otoscopic examination negative. No weakness of the extremities nor can any 
sensory impairment be ascertained. Pupils rather contracted equally but 
react to light normally. Reflexes: patellar — left more active than right: 
no ankle clonus ; left Babinski ; abdominal reflexes — left possibly less active 
than right. Fundi — retinal veins slightly enlarged ; no edematous blurring 
of the details of either optic disk. Lumbar puncture — clear cerebrospinal 
fluid under approximately 9 mm. pressure ; 12 c.c. carefully withdrawn until 
the pressure was approximately 7 mm. 

Treatment. — Expectant palliative continued. The improvement of the 
general condition of the patient rapidly progressed; he complained, how- 
ever, of rather severe headache, although it was greatly lessened for about 
6 hours following each lumbar puncture. Upon the following day, the fifth 
and last lumbar puncture was performed and 12 c.c. of cerebrospinal fluid 
under a pressure of approximately 9 mm. were carefully removed — the pres- 
sure at the end of the drainage being approximately 7 mm. The patient 
now felt so much better that he desired to get out of bed and to go home 
the following day; it was with difficulty that he could be kept in the hospital 
and he finally persuaded his parents to insist upon his discharge on the tit'th 



564 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

day after the injury; they accordingly signed the hospital release of all 
responsibility — "at own risk/' 

Examination at discharge (114 hours after injury). — Temperature, 
98.8° ; pulse, 88 ; respiration, 22 ; blood-pressure, 114. Perfectly conscious but 
rather irritable ; upon questioning, patient admits he has a dull headache. 
Right parietal area slightly contused and boggy ; no orbital ecchymoses. No 
weakness of the extremities elicited by the special tests. Pupils of normal 
size and reaction. Reflexes — equally active but otherwise negative ; no Babin- 
ski. Fundi — retinal veins possibly slightly enlarged but otherwise negative. 

Treatment. — Parents advised to keep the patient at home and in bed, if 
possible, and that he should lead a very quiet and inactive life for a period 
of 3 months at least; not to play in the hot sun; a vegetable diet; 
daily catharsis. 

Examination (April 20, 1917 — 32 months after injury) . — No complaints ; 
attends school daily and ' ' could not be better " ; no headache nor convulsive 
seizure since his discharge from the hospital. Reflexes present and equal. 
Fundi negative. 

Last Report (June 6, 1919 — 58 months after injury). — Letter from 
father states: "William is a well boy in every way; at times he becomes 
irritable but not more than the other children. No headache or fits. His 
teacher's reports are about the average." 

Remarks. — The clinical history of this patient would indicate that a 
localized cerebral edema of the right motor cortex had occurred and of such 
mild degree that its irritative presence had produced the Jacksonian con- 
vulsive seizures of the left arm and left leg, and yet the cortex itself was 
not so water-logged or compressed as to produce a definite paralysis of the left 
arm and the left leg ; the contraction of the pupils would confirm the irrita- 
tive effect of the cortical lesion — the initial pupillary enlargement being 
undoubtedly due to the mild condition of the shock following the cranial 
injury. The repeated lumbar punctures and drainage of much clear cerebro- 
spinal fluid undoubtedly facilitated the recovery of this patient, although 
even without the) lumbar punctures it is probable that this patient would 
have made an excellent recovery under the expectant palliative treatment 
alone — merely a longer time being required for the convalescence; it is 
possible, however, that the cranial operation of right subtemporal decompres- 
sion and drainage would have been indicated, and therefore it is considered 
that the spinal drainage formed an essential factor in the treatment of this 
patient and similarly selected patients, in whom the intracranial pressure is 
not so markedly increased that this method of spinal drainage would be a 
definite risk and danger to the patient. 

The presence of the contusion of the scalp and the hematoma overlying 
the right parietal area would tend to point to the direct cranial injury 
as being an important factor in causing the localized cerebral edema directly 
beneath this part of the vault ; the bilateral contraction of the pupils would 
indicate that the cortex of both hemispheres was equally irritated by the 
cortical edema, and therefore it is probable that the right motor cortex 
was only more so and to the extent of causing the localized convulsive seiz- 
ures of the left arm and the left leg. It is possible for small supracortical 






IN NEWBORN BABIES AND CHILDREN 565 

subarachnoid hemorrhages to occur in these patients having injuries to the 
vault directly over the cerebral cortex and even numerous punctate hemor- 
rhages within the cortex, but this complication is rather rare; in many 
patients, the cerebrospinal fluid at lumbar puncture will show the presence 
of blood and it is frequently advisable in these latter patients to perform 
the operation of cranial decompression and drainage, when the intracranial 
pressure is definitely increased — for fear of future complications and 
especially of convulsive seizures. 

It is essential that patients of this character should receive most careful 
treatment in that all vigorous physical and mental work should be avoided 
for a period of months and that their lives should be regulated by careful 
hygienic rules — the avoidance of alcohol, meats, meat-soups, tea and coffee. 

Case 146. — Acute severe brain injury associated with a subdural hemor- 
rhage and with a mild increase of the intracranial pressure ; motor aphasia. 
Repeated lumbar punctures and drainage. Excellent recovery. 

No. 704. — George. Eleven years. White. School. U. S. 

Admitted October 17, 1916. Polyclinic Hospital. 

Discharged October 31, 1916 — 14 days after injury. 

Family history negative; both parents and grandparents were 
right-handed. 

Personal History. — Negative. Patient is right-handed. 

Present Illness. — While engaging in a street fight, patient was struck 
over the left side of his head with a small piece of lead pipe ; apparently 
no complete loss of consciousness — merely stunned but he was unable to 
talk and gradually became stuporous. Patient was able to walk to the 
hospital supported by an older boy. 

Examination upon admission (1 hour after injury). — Temperature, 
99° ; pulse, 74; respiration, 22; blood-pressure, 114. Rather stuporous and 
drowsy; unable to answer questions — merely shakes head for yes or no, 
but he is able to write the following: "I have a bad headache"; "My right 
hand feels like pins and needles " ; " Everything is moving about me. ' ' 
No definite weakness of right side of the body nor any impairment of sen- 
sation could be elicited by special tests ; no astereognosis nor apraxia. Small 
hematoma just below the left parietal crest; not particularly tender. No 
bleeding from the nose, mouth or ears ; no orbital nor mastoid ecchymoses. 
Pupils equal and of normal reaction to light. Reflexes — patellar exagger- 
ated, right more than left; exhaustible right ankle clonus and suggestive 
bilateral Babinski ; abdominal reflexes — right absent. Fundi : retinal veins 
enlarged — left possibly more than right; nasal margin of left optic disk 
obscured by edema. Lumbar puncture — blood-tinged cerebrospinal fluid 
under a slightly increased pressure (approximately 10 mm.) ; 15 c.c. care- 
fully removed. 

Treatment. — Expectant palliative ; for fear that a hemorrhage was occur- 
ring over the left cerebral cortex, the patient was repeatedly examined 
so that this serious complication could be recognized as early as possible and 
a left subtemporal decompression advised during the early stage, and thus 
the damaging effects of such local compression and the resulting general 
effects upon the medulla be anticipated and therefore avoided. The con- 



566 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

dition of the patient, however, remained practically the same, except that 
the ophthalmoscope, 6 honrs after admission, revealed an edematous blurring 
of the nasal margins of both optic disks and a slight obscuration of a nasal 
half of the left optic disk — signs of an increasing intracranial pressure ; a 
second lumbar puncture and drainage was now performed and 16 c.c. of 
blood-tinged cerebrospinal fluid were removed — the pressure at the begin- 
ning being approximately 12 mm. and at the end of the puncture only 9 mm. 
An almost immediate improvement appeared in that the patient became 
brighter and more alert, was able to say several words — among them being 
"I feel much better." A third lumbar puncture was performed upon the 
following day and 14 c.c. of straw-colored cerebrospinal fluid were removed — 
the pressure at the beginning being only approximately 10 mm. and at the 
end of the puncture approximately 8 mm. ; the general and local condition 
of the patient continued to improve— speech was more smooth and of larger 
vocabulary, the headache less severe and the numbness and tingling of the 
right side of the body disappeared. A fourth lumbar puncture, however, 
was performed upon the following day and 15 c.c. of slightly straw-colored 
fluid were withdrawn — the pressure at the beginning being only approxi- 
mately 9 mm. and at the end of the puncture being only 7 mm. From this 
time on, the patient made an uneventful recovery. 

Examination at discharge (11 days after admission). — Temperature, 
98.6°; pulse, 82; respiration, 24; blood-pressure, 116. Apparently normal 
mentally and emotionally ; a very slight difficulty in speech but only to be 
elicited by test phrases ; no sensory aphasia. No weakness of the right side 
of the body nor impairment of sensation. Hearing negative ; otoscopic 
examination negative. Pupils negative. Reflexes : patellar active, right 
possibly more than left; no ankle clonus nor Babinski; abdominal reflexes 
— right possibly less active than left. Fundi — retinal veins slightly 
enlarged ; lower portion of nasal margins of left optic disk indistinct from 
edema. X-ray report (Doctor William H. Stewart) — "no fracture of the 
skull is shown." 

Examination (January 10, 1918 — 15 months after injury). — No com- 
plaints referable to the head injury. No impairment of speech can be 
obtained by special test phrases and patient stands well in his school classes. 
Reflexes active but otherwise negative. Fundi negative. 

Last Report (April 20, 1919 — 30 months after injury). — Father writes: 
"Except for an attack of typhoid fever, George has been well and has no 
complaints. Will smoking hurt him?" 

Remarks. — If this patient had shown a higher intracranial pressure, it 
would then have been advisable to have performed an early left subtem- 
poral decompression and drainage rather than to have run the risk of a 
permanent damage to the underlying cerebral cortex; also if Jacksonian 
convulsive seizures had occurred, then too, it would have been dangerous 
to have delayed the cranial operation and drainage. The patient being 
repeatedly examined and under close observation and the intracranial 
pressure not being high, it was considered a rational method of treatment 
to perform repeated lumbar punctures and drainage and then, if the con- 
dition of the patient did become worse or if complications appeared, then 



IN NEWBORN BABIES AND CHILDREN 567 

the cranial operation of left subtemporal decompression and drainage could 
be advised. The excellent result obtained in this patient would tend to 
justify this method of treatment in certain selected patients and especially 
in children. 

It is very rare for cases of pure motor aphasia to occur and for such 
an excellent recovery to result ; usually the motor aphasia is associated with 
some degree of sensory aphasia or even with the condition, more or less 
complete, of astereognosis and also of apraxia. This condition of pure motor 
aphasia possibly occurs most frequently in these traumatic patients due to a 
localized supracortical hemorrhage or even to a localized cortical edema 
of mild degree. The parents and grandparents all being right-handed and 
the patient himself also being right-handed, would place the motor speech 
area in the left cerebral cortex. The absence of an overlying fracture of 
the skull at the site of the area of contact of the lead pipe tends to confirm 
again the statement that the fracture of the skull is possibly the most 
unimportant factor in brain injuries. 

Case 147. — Acute severe brain injury associated with extensive linear 
fractures of the vault but with only a mild increase of the intracranial 
pressure. No operation; repeated lumbar punctures and drainage. Excel- 
lent recovery. 

No. 826.— Peter. Six years. White. School. U. S. 

Admitted April 15, 1917. Polyclinic Hospital. 

Discharged May 3, 1917 — 18 days after injury. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon the roof of a shed, patient fell to 
the ground — a distance of 30 feet, striking upon the left side of head ; imme- 
diate loss of consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 98°; pulse, 130; respiration, 32; blood-pressure, 96. Semiconscious; 
in profound shock. Extensive bruise over left forehead with a bogginess 
in the left temporo-parietal area. Small amount of clotted blood in left nos- 
tril ; no bleeding from mouth or ears ; no mastoid ecchymoses. Diffuse left 
conjunctival ecchymosis; left orbital tissues so swollen and ecchymosed 
that patient cannot open left eye. No paralyses ascertained. Pupils en- 
larged and react to light sluggishly. Eeflexes all abolished. Fundi negative. 

Treatment. — On account of the severity of the shock, only a superficial 
examination was made at this time. Vigorous measures immediately insti- 
tuted in the hope that the shock could be survived : rectal enemata of hot 
black coffee, heated blankets and several hot water bags; absolute quiet. 
Within 3 hours the general condition had improved, and at the end of 
8 hours the severe condition of shock had almost disappeared. 

Examination (12 hours after admission). — Temperature, 99° ; pulse. 96: 
respiration, 26 • blood-pressure, 110. Stuporous but can be aroused to answer 
questions in a confused manner. Boggy ecchymosis of left orbit and left 
side of head — a "doughy" feeling as of fluid in the subcutaneous tissues 
of the scalp. Marked area of tenderness over the left half of the frontal 
bone. No paralysis or impairment of sensation. Pupils — left possibly 



568 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



larger than right (most probably due to the local orbital condition) ; reaction 
to light normal. Reflexes — patellar present and equal; no ankle clonus 
but suggestive right Babinski; abdominal reflexes absent. Fundi — retinal 
veins enlarged; mild blurring of nasal margins of both optic disks. Lum- 
bar puncture — bloody cerebrospinal fluid under a slightly increased pressure 
(11 mm.) ; 15 c.c. removed slowly and carefully. X-ray (Doctor G. W. 
Welton) — "a line of fracture extends through the left vertical plate of the 
frontal bone backward and forks — one upward and terminating near the 
coronal suture, while the other passes obliquely downward into the left 

parietal bone ; another line 

r- of fracture extends forward 
.^ a g gH - • . through the right half of the 

frontal bone" (Fig. 165). 
Treatment. — In the hope 
that the expectant palliative 
treatment aided by repeated 
lumbar punctures to drain 
the hemorrhage would be 
sufficient, this patient was 
actively treated in the rou- 
tine manner and a steady 
daily improvement occurred. 
Repeated daily lumbar punc- 
tures were performed upon 
five consecutive days and at 
each time 15 c.c. of bloody 
cerebrospinal fluid were 
carefully and slowly re- 
moved, so that on the fifth 
day the pressure of the 
cerebrospinal fluid was only 
9 mm. and straw-colored, 
whereas on the second day 
it had been 12 mm. and 
bloody. The boggy ecchymosis and edema of the left side of the scalp 
persisted for 10 days and then gradually subsided — apparently an excellent 
means of drainage of intracranial hemorrhage and cerebrospinal fluid 
through the lines of fracture. 

Examination at discharge (18 days after injury). — Temperature, 
98.6° ; pulse, 82 ; respiration, 24; blood-pressure, 114. No complaints except 
for general soreness over the left half of the head. Small amount of left 
subconjunctival hemorrhage persists. Pupils equal and react normally. Re- 
flexes negative. Fundi — retinal veins slightly enlarged; margins of optic 
disks clear and distinct. 

Treatment. — Parents advised that the child should not be allowed to play 
vigorously or become unusually excited for a period of three months; the 
avoidance of meat, meat-soups, tea and coffee ; the importance of a daily 
movement of the bowels was emphasized. 




Fig. 165. — Multiple linear fractures of the anterior portion 
of the vault, in a patient having a mild increase of the intra- 
cranial pressure; spinal drainage by means of repeated lumbar 
punctures. Excellent recovery. 



IN NEWBORN BABIES AND CHILDREN 569 

Examination (February 20, 1918 — 10 months after injury). — No com- 
plaints, except his school-teacher states that child "is not as bright as 
formerly." Reflexes negative. Fundi negative. 

Last Examination (May 6, 1919—25 months after injury). — No com- 
plaints; father states that "Peter is as well as ever and his school 
reports are good." Pupils equal and react normally. Reflexes negative. 
Fundi negative. 

Remarks. — The extensive linear fractures of the left vault undoubtedly 
provided a means for the escape of intracranial hemorrhage and excess 
cerebrospinal fluid, and thus aided in the lowering of the intracranial pres- 
sure so that the operation of decompression and drainage could be avoided ; 
whether this means in itself would have sufficed in this patient unless it had 
been aided by the repeated lumbar punctures and spinal drainage cannot 
be asserted with accuracy, but in some patients these linear fractures of the 
vault making possible the escape of intracranial hemorrhage and edema 
into the subcutaneous tissues of the scalp to form hematomata and diffuse 
boggy ecchymoses, are of definite therapeutic value. The danger of infection 
of the hematomata in these patients is a definite one, if the overlying scalp 
is very tense for a period of days or if the scalp itself is badly bruised and 
thus its resistance to infection lowered ; otherwise, the risk is slight. 

This case illustrates the comparative unimportance of the fracture of 
the skull, as a diagnostic means of the intracranial lesion and the necessity 
of a cranial operation or not ; in fact, in this particular patient the fractures 
of the vault facilitated the treatment of the patient and aided in makings 
unnecessary a cranial operation for decompression and drainage. 

The therapeutic value of repeated lumbar punctures is well illustrated, not 
only as a means of estimating accurately the important intracranial status of 
the patient, but of the greatest importance in children and only less so in 
adults, as a valuable means of drainage of both subdural blood and excess 
cerebrospinal fluid. Naturally, if the increased intracranial pressure is high, 
then this method of spinal drainage must not be attempted for fear of induc- 
ing most serious medullary complications of direct compression, but in the 
milder patients in whom the intracranial pressure does not exceed 15 mm. as 
registered by the spinal mercurial manometer, then this method of spinal 
drainage can at least be used in the hope that it will be sufficient to prevent 
the necessity of the cranial operation of decompression and drainage ; by 
careful estimation of the pressure of the cerebrospinal fluid at each puncture, 
it can be easily ascertained whether the intracranial pressure is gradually 
being lessened or not, and thus the patient is being afforded every chance of 
recovery at the least risk ; if the spinal punctures are not sufficient in them- 
selves to lower the increased intracranial pressure, then the operation of 
subtemporal decompression and drainage can be advised early and before the 
patient has reached the dangerous condition of severe medullary compression. 

Case 148. — Acute severe brain injury associated with extensive com- 
minuted linear fractures of vault and of the base of the skull, but with only 
a mildly increased intracranial pressure. No operation; repeated lumbar 
punctures and drainage. Excellent recovery. 

No. 949. — George. Seven years. White. U. S. 



570 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



Admitted February 13, 1918. Polyclinic Hospital. 
Discharged February 28, 1918 — 15 days after injury. 
Family history negative. 
Personal history negative. 

Present Illness. — While playing in the street, patient was struck by an 
automobile; immediate loss of consciousness; brought to the hospital in 
the ambulance. 

Examination upon admission (20 minutes after injury). — Tempera- 
ture, 98.6° ; pulse, 90 ; respiration, 28 ; blood-pressure, 100. Unconscious ; 
in mild shock. Multiple contusions and extensive hematomata of entire scalp 
— left half more than right. Profuse bleeding from left ear; left mastoid 

ecchymosis. Right orbital tis- 
sues ecchymosed but no subcon- 
junctival hemorrhage. No 
paralysis elicited. Pupils rather 
small but react to light normally. 
Reflexes — patellar absent ; no 
ankle clonus but left Oppenheim 
and Babinski reflex; abdominal 
reflexes could not be elicited. 
Fundi negative. 

Treatment. — Owing to the 
presence of shock, a more thor- 
ough examination was not made 
at this time; immediate routine 
treatment of the shock was insti- 
tuted and within four hours the 
general condition of the patient 
was much improved. Head care- 
fully shaved and a mild (1-5000) 
bichloride dressing applied. 

Examination (8 hours after 
admission). — Temperature, 99°; 
pulse, 88 ; respiration, 26 ; blood- 
pressure, 108. Semiconscious but cannot be aroused to answer questions. 
Entire scalp boggy and ecchymotic; not tense. Apparent crepitus can be 
elicited over the vertex. Discharge of blood from the left ear had ceased ; 
otoscopic examination revealed a large laceration in the lower posterior 
quadrant of the left tympanic membrane. No paralysis ascertained. Left 
mastoid and right orbital ecchymoses (Figs. 166 and 167). Pupils of 
normal and equal size with normal reaction to light. Reflexes — patellar 
present, left possibly more than right ; no ankle clonus but suggestive left 
Oppenheim and Babinski reflexes ; abdominal reflexes depressed but appar- 
ently equal. Fundi — retinal veins enlarged; hazy blurring of the lower 
nasal margins of both optic disks. Lumbar puncture — blood-tinged cere- 
brospinal fluid under a slightly increased pressure (10 mm.) ; 15 c.c. care- 
fully removed. X-ray (Doctor G. W. Welton) — "extensive linear fractures 
of the vault of the skull — more on the left side" (Fig. 168). 







i 



.Fig. 166. — Boggy left mastoid ecchymosis in a patient 
who bled profusely through a torn left tympanic 
membrane. Excellent recovery with the expectant pal- 
liative treatment. 



IN NEWBORN BABIES AND CHILDREN 



57i 



Treatment. — Expectant palliative; repeated daily lumbar punctures 
advised in the hope that they would facilitate the natural absorption of the 
increased intracranial pressure, prevent it from ascending to a height 
necessitating a cranial operation and at the same time be a means of 
draining the small amount of free blood in the cerebrospinal fluid. The 
extensive linear fractures, permitting the intracranial hemorrhage to escape 
through the left ear and also into the subcutaneous tissues of the scalp and 
there forming multiple hematomata with and without the mixture of 
cerebrospinal fluid, were a fortunate means of lessening the increased intra- 
cranial pressure and thus avoiding the necessity of a cranial operation 
of decompression and drainage. Eepeated daily lumbar punctures were 
performed upon four successive days and 15 c.c. of blood-tinged cerebro- 
spinal fluid slowly and carefully 
removed. On the second day, 
the pressure was increased (11 
mm. ) , whereas on the fourth day 
it was only 9 mm. The com- 
plaint of headache was relieved 
each time following the lum- 
bar puncture and removal of 
the fluid. 

Examination at discharge (15 
days after injury). — Tempera- 
ture, 98.6°; pulse, 82; respira- 
tion, 24 ; blood-pressure, 112. No 
complaints except a general sore- 
ness of the head, especially on 
the left side. Several ecchymot- 
ic areas throughout the scalp 
and over the left mastoid. No 
paralyses nor impairments of 
sensation. Hearing less in left 
ear and bone conduction was' 

greater than air conduction. Pupils equal and react normally. Fundi — 
retinal veins slightly enlarged ; details of optic disks clear and distinct. 

Treatment. — Parents cautioned regarding the diet of the child and 
especially the avoidance of meat, meat-soups, tea and coffee ; daily regulation 
of the bowels ; the avoidance of much excitement and vigorous play and at 
least 10 hours ' sleep each night — and better 12 hours; no school until the 
fall — 7 months later. 

Examination (August 22, 1918 — 6 months after injury). — No com- 
plaints; apparently "the same as before the injury." Palpation of loft 
side of vault elicits slight tenderness. Hearing of loft ear loss acute than of 
right; otoscopic examination reveals a healed scar in the posterior lower 
quadrant of the left tympanic membrane; bone conduction equals air con- 
duction. Reflexes — present and equal ; normal plantar flexion and rorlexes. 
Fundi negative. 

Last Examination (May 10, 1919 — 15 months after injury). — No com- 




Fig. 167. — Right orbital and multiple scalp ecchymoses 
in a patient having multiple fractures of the vault and of 
the base. The right mastoid ecchymosis is indistinctly 
shown. Excellent recovery with the expectant palli- 
ative treatment. 



572 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



plaints; goes to school daily and no mental or emotional impairment has 
been observed by teacher. Hearing of left ear of normal acuity and the 
air conduction is now greater than the bone conduction; otoscopic ex- 
amination — left tympanic membrane is negative. Reflexes negative. 
Fundi negative. 

Remarks. — The linear fractures of the vault of this patient were possibly 
the most extensive I have ever seen; upon bimanual examination, distinct 
crepitus could be elicited — almost a crackling sensation upon gentle biman- 
ual pressure. In this manner, such an excellent natural decompression had 
been formed and the escape and drainage of the intracranial hemorrhage and 
excess cerebrospinal fluid had been so profuse, that the increased intracranial 
pressure did not reach a height greater than 11 mm. and naturally, no 
cranial operation of decompression and drainage was advisable or at all 

necessary. The danger of 
an infective process extend- 
ing through the scalp into 
the multiple hematomata 
and then the great risk of 
a purulent meningitis re- 

( suiting, was less in this 

ft patient on account of the 
small amount of bruising of 
the scalp and the absence of 
a marked tenseness of the 
hematomata themselves ; 
the careful shaving of the 
entire head and the appli- 
cation of a mild antiseptic 
wet dressing of bichloride 
(1-5000) assisted in lessen- 
ing this danger of infection. 
This patient is another 
illustration of the compara- 
tive unimportance of linear 
fractures of the skull in the diagnosis and treatment of brain injuries — un- 
less considered as an aid in their treatment as in this patient. The presence 
of the left Oppenheim and Babinski reflexes for 2 days following the injury 
and then their gradual disappearance, was due most probably to a mild 
edematous condition of the right cerebral cortex — and not to a definite 
hemorrhagic clot formation, which would tend to prolong these signs of cor- 
tical and pyramidal tract involvement. Temporary edema of the cerebral 
cortex is a rather common occurrence in brain injuries in children and may 
be sufficient to cause localized epileptiform seizures, although in the presence 
of this latter complication, an immediate homolateral subtemporal decom- 
pression and drainage should be performed in order to lessen early this corti- 
cal irritation and thus avoid future complications. 

The rapid improvement of the hearing of the left ear with the early 
healing of the laceration of the left tympanic membrane is most impressive 




Fig. 168. — Extensive linear fractures of the anterior portion 
of the vault, in a patient having a mild increase of the intra- 
cranial pressure. Excellent recovery following the spinal drain- 
age of repeated lumbar punctures and the expectant pallia- 
tive treatment. 



IN NEWBORN BABIES AND CHILDREN 573 

and is characteristic of these middle ear traumatic impairments, where the 
tympanic membrane is the chief lesion. This is the usual result of similar 
lesions in adults, but in them the return to normality is not so rapid. The 
danger of infection through the ear in these patients is practically nil, unless 
meddlesome procedures of irrigation and "cleaning out" of the auditory 
canal are attempted. 

C. Acute cranial injuries associated with a depressed fracture of the 
vault. Removal of the depressed bone. Excellent recovery. 

Case 149. — Acute depressed fracture of the vault associated with an 
extensive linear fracture ; no increase of the intracranial pressure. Removal 
of the depressed bone. Excellent recovery. 

No. 728. — John. Four years. White. Holland. 

Admitted November 26, 1917. Polyclinic Hospital. 

Operation November 28, 1917 — 2 days after injury. Removal of de- 
pressed area of bone. 

Discharged December 12, 1917 — 14 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a fire-escape, child fell one flight to 
the cement pavement below; apparently no loss of consciousness; brought 
to the hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 110 ; respiration, 28 ; blood-pressure, 102. Very restless 
and crying; mild degree of shock. Hematoma over postero-superior por- 
tion of the right parietal bone. No bleeding from nose, mouth or ears; 
orbital and right mastoid ecchymoses. No paralyses. Pupils slightly en- 
larged but react normally. Reflexes — present and equal; no Babinski. 
Fundi negative. 

Treatment. — Expectant palliative. 

Examination (30 hours after admission). — Temperature, 99° ; pulse, 84; 
respiration, 24; blood-pressure, 112. Apparently well and wants to go 
home. Entire scalp ecchymotic — particularly boggy over the vertex and to 
the right of the midline. Bimanual examination is negative except for 
tenderness, especially over the right side of the vault. Both orbits and 
right mastoid area are ecchymosed. No paralyses nor impairments of 
sensation. Pupils equal and react normally. Reflexes — patellar active but 
equal ; no ankle clonus nor Babinski ; abdominal reflexes present and equal. 
Fundi — retinal veins possibly enlarged; no obscuration of the details of 
either optic disk. Lumbar puncture — clear cerebrospinal fluid under normal 
pressure (8 mm.). X-ray (Doctor G. W. Welton) — "shows a depressed 
fracture of the vault at the postero-superior angle of the right parietal 
bone ; there is a wide fracture line extending obliquely downward and for- 
ward to the base" (Fig. 169). 

Treatment. — An exploratory incision over the depressed area of the vault 
was advised for fear of the possible complication of infection and also of 
the future danger of convulsive seizures. 

Operation (40 hours after admission). — Removal of depressed area of 
vault; small horseshoe-shaped incision of the edematous and hemorrhagic 



574 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




scalp, exposing a depressed area of both tables of the vault of about the size 
of a silver quarter. In order to remove the depressed area of bone, a tre- 
phine opening was made upon either side of the depression, the opening 
enlarged and the fragment of bone taken out; a sharp-pointed portion 
pressing against the dura and tearing it was carefully removed ; the under- 
lying cortex apparently not damaged. It was possible to see and to feel 
the wide linear fracture extending downward from this area as disclosed 
by the roentgenogram. No attempt was made to suture the dural opening 
(the size of one-quarter inch in length) and a small drain of rubber tissue 
was inserted into this opening. Brain itself was not under increased press- 
ure. Usual closure of the scalp with two drains of rubber tissue inserted 

down to the dura. Dura- 
tion, 30 minutes. 

Post-operative Notes. — 
Uneventful recovery and 
convalescence. Incision 
healed per primam. 

'Examination at discharge 
(14 days after operation). — 
Temperature, 98.6° ; pulse, 
82; respiration, 24; blood- 
pressure, 112. Xo com- 
plaints except general sore- 
ness of the head, especially 
the right side. Right orbit 
and right mastoid area are 
slightly ecchymotic. Hear- 
ing negative. Pupils nega- 
tive. Reflexes n e.g a t i v e . 
Fundi negative. The opera- 
tive area is slightly de- 
pressed ; normal pulsation ; 
incision entirely healed so that no gauze dressing was necessary. 

Examination (July 20, 1918 — 8 months after injury). — No complaints. 
Operative area depressed; slight pulsation visible. Reflexes negative. 
Fundi negative. 

Last Examination (May 8, 1919 — 18 months after injury). — No com- 
plaints. Operative area depressed ; slight pulsation visible. Reflexes nega- 
tive. Fundi negative. 

Remarks. — The importance of careful and routine X-ray pictures of all 
patients having cranial injuries is well emphasized in this case-history. It 
is possible that this depressed area of bone might have been overlooked in 
this patient until months or even years after — when symptoms and signs 
had developed, and then it would have been late for the best results to be 
obtained. The ideal time for relieving the condition and for preventing 
untoward signs and complications is after the shock has been overcome ; 
the removal of the depressed area of bone under strict asepsis also lessens 




Fig. 169. — Huge linear fracture extending downward from a 
depressed fracture of the vault in a patient having no increase 
of the intracranial pressure. Excellent recovery following the 
expectant palliative treatment and a removal of the depressed 
area of bone. 



IN NEWBORN BABIES AND CHILDREN 575 

the danger of meningitic complications from infection of the hematoma of the 
scalp and especially if the adjacent skin has been badly contused. 

The absence of an increased intracranial pressure made it possible to 
remove the depressed bony fragment first and with safety without preceding 
it by the operation of subtemporal decompression, which should always first 
be performed if the intracranial pressure is definitely increased. The exten- 
sive fracture of the skull is interesting in view of the absence of unconscious- 
ness and also the signs of severe shock. It merely emphasizes the compara- 
tive unimportance of the fracturei of the skull, as an index of the severity 
of the brain injury — in fact, the presence of a fracture of the skull or not 
is of little importance — unless it is a depressed one of the vault, which should 
always be elevated or removed. 

Case 150. — Acute severe brain injury associated with extensive fractures 
of the vault and a depressed fracture of the right parietal bone ; no signs of an 
intracranial lesion or of an increased intracranial pressure. Operation to 
remove the depression of the vault refused, but 5 months later consent was 
obtained and the operation was then performed. Excellent recovery. 

No. 922. — John. Pour years. White. Holland. 

Admitted June 26, 1917. Polyclinic Hospital. 

Discharged June 27, 1917 — 22 hours after admission. Operation refused. 

Operation, November 28, 1917 — 5 months after injury. Removal of de- 
pressed area of vault. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a fire-escape, child fell to the stone 
sidewalk below — a distance of 18 feet — striking upon the right side of head ; 
merely stunned but no loss of consciousness; brought to the hospital in 
the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.6° ;' pulse, 108 ; respiration, 28 ; blood-pressure, 100. Rather stupor- 
ous and drowsy, but cries for his mother when aroused ; in mild condition of 
shock. Contusion of scalp over right parietal area ; careful palpation of this 
region reveals an apparent depression of the underlying bone and the sensa- 
tion of a " crack " extending downward. No bleeding from nose, mouth or 
ears ; no orbital or mastoid ecchymoses ; otoscopic examination negative. No 
paralysis of the extremities elicited. Pupils equal and react to light nor- 
mally. Reflexes — patellar present and equal ; no ankle clonus nor Babinski .- 
abdominal reflexes possibly depressed but equal. Fundi negative. Lumbar 
puncture — clear cerebrospinal fluid under normal pressure (8 mm.). X-ray 
report (Doctor G. W. Welton) — "bony depression of the krwer posterior 
portion of the right parietal bone — almost 2 cm. in diameter ; wide linear 
fracture — almost a defect — extends downward from this depressed area" 
(Fig. 170). 

Treatment. — Expectant palliative method. Within one hour, the child 
reacted strongly so that the general condition was considered excellent ; 
upon repeated examinations within the next 12 hours, the patient disclosed 
no neurological signs of an intracranial injury and there were no signs of 
an increased intracranial pressure. On account of the depression of the 






576 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



right parietal bone, the father of the child was advised to give his consent 
for an elevation or removal of the depressed bone, for fear of future compli- 
cations and particularly the great danger of a resulting cortical irritation 
and convulsive seizures ; the father, however, refused, and as the child was 
apparently normal in every way, except for the slight contusion of the scalp 
of the right side of the head and the definite local tenderness, he insisted 
upon taking the child home on the day after admission — 22 hours after the 
injury. The parent was advised to bring the child back to the hospital, if 
any symptoms or signs of the head injury should later appear. 

Five months later, the father brought the child to the hospital, and 
although there had been no complaints following the cranial injury and the 
child was apparently as well as ever, yet the father had been told by a bar- 
tender that head injuries, 
even years afterward, ' ' often 
caused fits and such things 
by a piece of bone sticking 
into the brain"; naturally, 
the father now feared for 
the boy's future and accord- 
ingly brought him to the 
hospital '"for the cutting." 
Examination upon the 
second admission of the child 
(November 26, 1917—5 
months after injury) . — Tem- 
perature, 98. 6 = ; pulse. 82; 
respiration, 24 ; blood-pres- 
sure, 110. Of normal men- 
tality. No signs of former 
head injury, except a defi- 
nite depression of the lower 
posterior portion of the right 
parietal bone can still be 
palpated — the size of a silver quarter: the linear fracture extending down 
from this depression can also be palpated — apparently almost one-quarter 
inch in width at its upper portion. No paralyses or sensory impairments 
elicited. Hearing negative. Pupils equal and react normally to light. 
Reflexes negative. Fundi negative. Lumbar puncture — clear cerebrospinal 
fluid under normal pressure (8 mm.). 

Treatment. — For fear of future intracranial complications resulting from 
the depressed area of the vault, an operation to elevate or remove the 
depressed bony fragment was performed. 

Operation (5 months after injury). — Removal of the depressed area of 
vault : small horse-shoe incision of 2 inches over the depressed area of the 
lower posterior portion of the right occipital bone ; upon retraction of the 
scalp, a rectangular bony fragment of 3 cm. long and 1 cm. wide was found 
depressed to a distance of almost 1 cm. It was impossible to insert the 
rongeurs at the edge of the bony depression, so that it was necessary to 




Fig. 170. — Irregular depressed area of bone and wide linear 
fracture in a patient having no increase of the intracranial 
pressure. Later removal of the depressed bone. Excel- 
lent recovery. 



IN NEWBORN BABIES AND CHILDREN 577 

make a small trephine opening at the anterior edge ; the rongeurs were in- 
serted, the opening enlarged and the depressed bony fragment was removed. 
It was found that a small tear of the underlying dura had been made by the 
pointed bony edge, but no other lesion was observed and the underlying 
cortex pulsated normally and under normal tension. A small piece of the 
pericranium was placed over the dural opening and the scalp sutured after 
2 drains of rubber tissue had been inserted. Duration, 25 minutes. 

Post -operative Notes. — An uneventful convalescence occurred, so that 
child was discharged on the eighth day after operation — the neurological 
examinations being negative as before the operation. A post-operative 
rontgenogram was now taken, ' ' showing the bony defect due to the removal 
of the depressed area of bone ; descending line of fracture! very faint. ' ' 

Last Examination (May 21, 1919 — 23 months after injury and 18 months 
after operation). — No complaints — "as if the bump had not happened"; 
went to primary class during the past year and his reports were good. Site 
of operation pulsates slightly; bony opening smaller from new bone for- 
mation about its periphery. Reflexes negative. Fundi negative. 

Remarks. — The extensive fractures of the skull in this patient, as demon- 
strated by the rontgenogram and at operation, in the absence of any intra- 
cranial lesion of hemorrhage or cerebral edema, illustrate again the com- 
parative unimportance of the fractures of the skull following cranial injuries 
in the diagnosis and prognosis of these patients; in the absence of the 
depression of the vault, no operation would have been indicated, and it is 
possible for this patient to have obtained an excellent ultimate result even 
without the removal of the depressed area of the vault, and yet it was too 
great a risk to permit this child to undergo for fear that future compli- 
cations might occur; therefore, the removal of the depressed area of the 
vault was advised in the absence of all neurological signs and merely as a 
prophylactic measure. 

The clear cerebrospinal fluid as obtained by lumbar puncture imme- 
diately following the cranial injury tended to exclude an intracranial hemor- 
rhage and this is usually true, although it is possible for an extensive sub- 
dural hemorrhage to be present and yet the cerebrospinal fluid at lumbar 
puncture be clear; this is probably due to a blockage of the cerebrospinal 
fluid in the neighborhood of the foramen magnum. 

It must be remembered in these patients that the risk of the simple 
elevation and removal of a depressed fracture of the vault is practically nil, 
and that only primary anesthesia is necessary in children and the more 
nervous of the patients, while the local anesthesia of novocaine is very satis- 
factory for the more stable patients. 

Case 151. — Acute severe brain injury associated with a depressed frac- 
ture of the skull and with marked signs of an increased intracranial press- 
ure ; laceration of the right frontal lobe. Subtemporal decompression first 
and then a removal of the depressed area of bone. Excellent recovery. 

No. 1024.— Peter. Seven years. White. School. U. S. 

Admitted September 21, 1918. Polyclinic Hospital. 

Operation September 25, 1918 — 1 days after admission. First, right 
subtemporal decompression; second, removal of depressed area of vault. 
37 






578 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Discharged October 10, 1918 — 15 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a fire-escape, child fell headlong 
to the cement pavement — a distance of 25 feet — striking upon his right fore- 
head; immediate loss of consciousness; patient was found by a policeman, 
lying upon the pavement, and was brought to the hospital. 

Examination upon admission (about one hour after injury). — Tem- 
perature, 98°; pulse, 126; respiration, 30; blood-pressure, 102. Semicon- 
scious ; moderate degree of shock. Hematoma over the right half of frontal 
bone — the size of a lemon ; not tense and palpation elicits crepitus and an 
apparent depression of the underlying bone. Clotted blood in both nostrils, 
but no bleeding from the mouth or ears; right orbital ecchymosis but no 
mastoid discoloration. No paralyses elicited. Pupils — enlarged, equal and 
react to light sluggishly. Reflexes all abolished. Fundi negative. No 
further examination was made on account of the severity of shock. 

Treatment. — Vigorous shock measures instituted; routine expectant 
palliative treatment. Child rapidly recovered from the shock so that in 
the morning, 12 hours later, the following examination was made: 

Examination (12 hours after admission). — Temperature, 99° ; pnlse, 88; 
respiration, 24; blood-pressure, 114. Perfectly conscious; when asked how 
he was, he replied, "I feel fine." Right orbit closed by ecchymotic swelling, 
while the adjacent hematoma had become larger and more tense ; only slightly 
tender. No paralyses or impairments of sensation. Pupils of normal size 
and reaction. Reflexes — patellar exaggerated but equal ; no ankle clonus 
but double Babinski ; abdominal reflexes absent. Fundi — retinal veins 
dilated ; nasal halves and temporal margins of both disks blurred by edema. 
Lumbar puncture — blood-tinged cerebrospinal fluid under a mild pressure 
(11 mm.). X-ray (requested but unfortunately it was not taken until 3 
days later, due to necessary repairs upon the X-ray machine) Doctor 
G. W. Welton — "large depressed fracture of the right half of the frontal 
bone ; linear fracture extends vertically downward from this depressed area 
into the squamous portion of right temporal bone" (Fig. 171). 

Treatment. — The signs of a definite increase of the intracranial pressure 
not becoming more marked, the patient was treated expectantly until it was 
definitely ascertained by the rontgenograms that a depressed fracture of the 
frontal bone was present. An immediate operation was advised; owing to 
the increased intracranial pressure, a right subtemporal decompression was 
performed first and then the removal of the depressed area of the 
vault followed. 

Operations (4 days after admission). — First. Right subtemporal decom- 
pression : usual vertical incision, bone removed, and no complications ; in 
the temporal muscle beneath the temporal fascia was found much free clotted 
blood, indicating a fracture of the underlying bone, which was found extend- 
ing backward along the upper portion of the squamous bone ; a small amount 
of extradural clotted blood removed. Dura tense and bluish ; upon incising 
it, bloody cerebrospinal fluid spurted to a height of 2 inches, revealing 
a "wet," edematous cortex but no cortical hemorrhages or lacerations 



IN NEWBORN BABIES AND CHILDREN 



579 






observed. Cortex tended to bulge, but owing to the escape of much, cere- 
brospinal fluid, it receded at the end of the operation and pulsated slightly. 
Usual closure with 2 drains of rubber tissue inserted. 

Second. Removal of the depressed bone : vertical incision of 3 inches 
over the hematoma and the site of the depressed area of the vault. Upon 
retracting the scalp, much clotted blood and macerated brain tissue welled 
out of cavity, exposing a triangular depressed area of bone of 2 inches in 
diameter and extending through the torn dura into the underlying cortex. 
This fragment of depressed bone was carefully removed with rongeurs, the 
dura sutured and a small drain of rubber tissue inserted subdurally into 
the laceration of the brain. Usual closure with 2 drains of rubber tissue 
inserted beneath the scalp. Duration, 80 minutes. 

Post-operative Notes. — Uneventful operative recovery ; much bloody and 
then straw-colored cerebro- 
spinal fluid was drained; 
all drains removed on the 
second day and sutures on 
the sixth day post-operative. 

Examination at dis- 
charge (13 days after 
operation) . — Temperature, 
98.6°; pulse, 80; respira- 
tion, 24 ; blood-pressure, 
114. No complaints except 
for soreness about the 
operative areas. No im- 
pairment mentally or 
emotionally elicited ; no 
paralyses or sensory dis- 
turbances. Pupils equal 
and react normally. Re- 
flexes: patellar active but 
equal ; no ankle clonus nor Babinski — possibly a tendency to a Babinski on 
the left foot; abdominal reflexes. — left depressed. Fundi — retinal veins 
possibly enlarged ; no obscuration of details of either optic disk. 

Treatment. — Parents cautioned to restrict the child's activities for a 
period of 3 months at least; no meat, meat-soup, tea or coffee; daily 
bowel movement. 

Examination (June 10, 1919 — 4 months after injury). — No complaints: 
is going to school and "seems as well as ever." Operative sites slightly 
depressed but the pulsation is normal. Reflexes active but otherwise 
negative. Fundi negative — possibly slight enlargement of the retinal veins. 

Last Examination (May 21, 1919 — 8 months after injury). — No com- 
plaints — "just like any other child." Operative sites more depressed than 
at preceding examination. Reflexes negative, exeept for a less active left 
abdominal reflex. Fundi negative. 

Remarks. — The importance of an X-ray picture in all cranial injuries is 
well illustrated in this patient; if the depressed fracture of the vault had 







Fig. 171. — Huge depressed fracture and radiating wide linear 
fracture of right half of frontal bone in a patient having a high 
intracranial pressure; right subtemporal decompression first 
and then a removal of the depressed bone. Excellent recovery. 



5 8o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

not been demonstrated, then naturally no operation would have been indi- 
cated since the intracranial pressure was not high enough in itself to warrant 
the operation of decompression and drainage, and the presence of the over- 
lying hematoma made impossible an accurate diagnosis of the underlying 
depressed fracture of the vault; when satisfactory rontgenograms are not 
available, then an exploratory incision of the scalp should be performed for 
fear of future complications, both mentally and emotionally, and especially 
in regard to convulsive seizures. In this patient a subtemporal decompres- 
sion was first performed for fear of producing still greater damage to the 
underhung cerebral cortex, while attempting to remove the bony depression 
— a frequent disaster when this precaution is not taken. 

The absence of clinical signs of the cortical laceration other than the 
temporary ones of increased reflexes, and particularly the Babinski (which 
was bilateral), is a common observation in patients when the comparatively 
' ' silent areas ' ' of the cerebral cortex are involved — and possibly most of all, 
the right frontal lobe in right-handed patients and then the right temporo- 
sphenoidal lobe. Naturally, sufficient time has not elapsed since the injury 
to estimate the effects of this intracranial injury upon the future mental and 
emotional development of the child or whether he will continue to remain 
as normal as before the injury ; it is very doubtful and yet similar cases of 
years in duration have had that fortunate end-result. The danger, however, 
of emotional instability at least is very great indeed. 

D. Acute train injuries associated with an increased intracranial pres- 
sure. Subtemporal decompression and drainage. Excellent recovery. 

Case 152. — Acute severe brain injury associated with a fracture of the 
base of the skull and with high intracranial pressure due to cerebral edema. 
Right subtemporal decompression and drainage. Excellent recovery. 

No. 046.— Mary. Four years. White. U. S. 

Admitted May 23, 1913 — 3 hours after injury. Polyclinic Hospital. 
Referred by Doctor J. A. Bodine. 

Operation (May 23, 1913 — 3 hours after admission). Right subtemporal 
decompression and drainage. 

Discharged June 5, 1913 — 12 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness,. — While playing in the street, child was struck by an 
express wagon ; no known loss of consciousness, but she became very drowsy 
within one hour and bled from the right ear; brought to the hospital in 
the ambulance. 

Examination upon admission (3 hours after injury). — Temperature, 
100.4° ; pulse, 66 ; respiration, 16 ; blood-pressure, 120. Well-nourished white 
child. Semiconscious ; no signs of shock. Bimanual examination of head is 
negative. Small amount of blood trickling from the right ear; no cerebro- 
spinal fluid observed. Right mastoid ecchymosis. Pupils equal and of 
normal reaction. Reflexes — knee-jerks active, right possibly greater than 
left ; tendency to a right Babinski ; abdominal reflexes present, left possibly 
greater than right. Fundi — definite fulness of retinal vessels with slight 
edematous haziness over the nasal halves of both optic disks. Lumbar 



IN NEWBORN BABIES AND CHILDREN 581 

puncture — cerebrospinal fluid slightly blood-tinged and under high pressure 
(approximately 21 mm.) ; only 4 c.c. removed for examination. 

Treatment. — An immediate right subtemporal decompression and drain- 
age advised to lower this high intracranial pressure for fear of acute medul- 
lary complications. 

Operation (3 hours after admission). — Right subtemporal decompression 
(primary anesthesia) : usual vertical incision and bone removed; no compli- 
cations. Dura very tense, and upon incising it, the slightly blood-tinged 
cerebrospinal fluid spurted a distance of 9 inches — striking the operator 
in the left eye and passing even behind his head. The underlying cerebral 
cortex was very "wet" and edematous with its vessels markedly congested; 
no hemorrhage or cortical laceration visible. The bulging cortex became less 
tense as the excess cerebrospinal fluid escaped, so that at the end of the 
operation the pulsation of the brain was almost normal. Usual closure 
with one drain of rubber tissue inserted beneath the right temporo-sphenoidal 
lobe and emerging at the lower angle of the incision. Duration, 38 minutes. 
Post-operative Notes. — Uneventful recovery and convalescence ; the drain 
was removed on the second day upon the lessening of the drainage of clear 
cerebrospinal fluid. Child became perfectly conscious and improved rapidly. 
Examination at discharge (12 days after operation). — Temperature, 
98.8° ; pulse, 84 ; respiration, 24; blood-pressure, 116. No complaints except 
the usual soreness at the site of operation ; this bulged slightly but pulsated 
normally. Hearing of right ear less than left ; bone conduction greater than 
air conduction in right ear; otoscopic examination discloses a tear in the 
upper posterior quadrant of the right tympanic membrane. Reflexes — 
active but otherwise negative. Fundi — retinal veins possibly enlarged but 
otherwise negative. X-ray report (Doctor A. J. Quimby) — "no fracture of 
the skull demonstrated. ' ' 

Examination (June 4, 1914 — 13 months after injury). — No complaints. 
The operative site is being narrowed by new bone formation — slightly convex 
outward. Hearing of right ear almost equals that of left ; bone conduction, 
however, equals air conduction. Reflexes negative. Fundi negative. 

Examination (September 16, 1917 — 40 months after injury). — No com- 
plaints; goes to school daily and "no different from the other children," 
writes teacher. New bone formation has almost entirely covered the decom- 
pression opening except at its posterior middle portion; slight pulsation 
palpable there. Hearing of both ears equally acute ; otoscopic examination 
of right ear negative, air conduction greater than bone conduction in both 
ears. Reflexes negative. Fundi negative. 

Last Examination (May 4, 1919 — 72 months after injury). — No com- 
plaints referable to the head. A very small irregular bony opening at the 
site of the former operation persists; no pulsation visible or palpable. 
Hearing negative. Reflexes negative. Fundi negative. 

Remarks. — The new bone formation which occurred in these patients be- 
fore the periosteum of the bone was removed at the time of the operation is 
not in any way harmful, unless there persists a mild chronic cerebral edema 
producing an increase of the intracranial pressure; in these latter patients. 
it would then be essential for this pressure to be entirely relieved by the 



582 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

patent decompression opening and the decompressive effects in no degree 
lessened; if, however, the increased intracranial pressure has disappeared, 
then there is no need for the bony decompression opening to remain patent. 
For fear, however, that this intracranial pressure does not subside to normal, 
it is essential that the decompression opening remain a permanent one, and 
for this reason, the so-called periosteum covering this bone is always removed, 
and during the past three years there has not been a patient in whom the 
operative site has been covered by a membrane formation — at most merely 
a slight narrowing of the opening at the bony margins alone. 

The excellent immediate and end-results of the patients of this character 
are most gratifying; a normal individual is obtained — emotionally, men- 
tally and physically, with little or no risk of future complications such as 
epileptiform seizures, etc. The rapid recovery of normal hearing of the 
impaired ear is the usual history of these patients, and especially in children, 
with and without operation. 

Case 153. — Acute severe brain injury associated with a fracture of the 
base of the skull and with signs of high intracranial pressure. Right sub- 
temporal decompression and drainage. Excellent recovery. 

No. 061.— Edwin. Five years. White. U. S. 

Admitted June 2, 1913. Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operation June 2, 1913 — 6 hours after admission. Right subtemporal 
decompression and drainage. 

Discharged June 16, 1913 — 14 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street, patient was knocked down 
by an automobile ; no known loss of consciousness ; cried for a period of 
30 minutes and then became drowsy ; profuse bleeding from the right ear 
with a small amount of cerebrospinal fluid mixed in the blood ; brought to 
the hospital in the ambulance. 

Examination upon admission (4 hours after injury). — Temperature, 
100.2°; pulse, 68; respiration, 18; blood-pressure, 116. Well-nourished 
white child ; semiconscious. No signs of shock. Many contusions over face 
and head ; ecchymosis of right orbit and over the right mastoid area. Clotted 
blood in the right auditory canal. No paralyses. Pupils of normal size and 
of normal reaction to light. Reflexes — patellar increased but equal ; no ankle 
clonus but a double Babinski ; abdominal reflexes absent. Fundi — retinal 
veins full; definite haziness and edema over the nasal margins and halves 
of both optic disks. Lumbar puncture- — clear cerebrospinal fluid under high 
tension (approximately 20 mm.) ; only small amount of fluid (3 c.c.) allowed 
to escape for fear of inducing a direct medullary compression. X-ray (Doc- 
tor A. J. Quimby) — "no fracture of the skull visible." (This picture was 
taken while waiting for the operating-room to be prepared.) 

Treatment. — An immediate right subtemporal decompression advised 
to anticipate a possible medullary edema. 

Operation (6 hours after admission). — Right subtemporal decompres- 
sion : usual vertical incision and removal of bone ; no complications. Upon 



IN NEWBORN BABIES AND CHILDREN 583 

incising the dura, which was under much tension, slightly blood-tinged 
cerebrospinal fluid spurted to a height of 2 inches, and upon enlarging 
the dural incision, the underlying arachnoid was punctured, allowing the 
cerebrospinal fluid to spurt to a height of 3 inches, and it continued to 
do so for almost 4 minutes; a second opening in the arachnoid spurted 
similarly. (This was the highest pressure I had ever observed in a child 
having a brain injury.) The cerebrospinal fluid was only slightly blood- 
tinged and owing to its rapid escape, the bulging cortex became more relaxed 
and its pulsation visible. Usual closure with one rubber tissue drain inserted 
beneath the right temporo-sphenoidal lobe into the middle fossa. Duration, 
40 minutes. 

Post-operative Notes. — No complications. Within 8 hours, the child be- 
came more normal mentally and cried for his mother. Profuse drainage of 
clear cerebrospinal fluid for 36 hours ; the drain was then removed. 

Examination at discharge (14 days after injury and operation). — 
Temperature, 98.8°; pulse, 82; respiration, 26; blood-pressure, 118. No 
complaints except for soreness at the site of operation. Decompression 
area bulges slightly beyond the flush of scalp ; normal pulsation. Oto- 
scopic examination reveals a torn right tympanic membrane in its lower 
posterior quadrant, hearing of right ear definitely impaired — bone conduc- 
tion being greater than air conduction. Pupils equal and of normal reac- 
tion. Reflexes : active but otherwise negative ; no Babinski. Fundi — retinal 
veins slightly enlarged but no edematous blurring of the details of either 
optic disk. 

Treatment. — Parents continued to keep the child quiet and in a non- 
excitable condition until the fall — a period of three months ; not to play in 
the sun ; light diet of no meat, meat-soup, tea or coffee — but rather vegetables, 
bread and milk ; daily movement of the bowels. 

Examination (June 7, 1914 — 12 months after injury).— No complaints; 
has been going to school during past winter and "does well." Operative 
bony opening is being narrowed and almost covered by new bone formation — 
slightly convex outward. (This occurred in several of the patients due to 
the periosteum of the bone not being entirely removed but merely scraped 
back ; during the past 3 years, the periosteum is always removed separately 
and this formation of new bone no longer occurs to any extent.) Hearing 
of right ear less acute than that of left ; bone conduction equals air conduc- 
tion in right ear. Reflexes negative. Fundi negative. 

Examination (September 12, 1916 — 39 months after injury). — No com- 
plaints; "the same as any other child," mother states. Site of operation 
entirely covered by new bone formation, slightly convex outward. Hearing 
of right ear equals that of left; air conduction greater than bone conduc- 
tion in both ears; otoscopic examination negative. Reflexes negative. 
Fundi negative. 

Last Examination (April 20, 1919 — 70 months after injury V — No com- 
plaints; "a strong, well boy in every way." Site of operation entirely 
covered by new bone formation. Hearing negative. Reflexes negative. 
Fundi negative. 

Remarks. — Several points are of interest in this case-history: 



584 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

The absence of any blood in the cerebrospinal fluid at lumbar puncture 
and yet its presence — though of mild degree — in the intracranial cerebro- 
spinal fluid is an observation of rather more frequency than is usually 
believed; merely because the lumbar puncture obtains clear cerebrospinal 
fluid is by no means conclusive that an intracranial hemorrhage of even the 
subdural and subarachnoid type is not present and, at times, in large amount. 

The high intracranial pressure in this child is the exception rather than 
the rule, but its cause being an excess of cerebrospinal fluid producing a 
' ' wet, ' ' edematous brain rather than a result of profuse hemorrhage, is the 
usual one — the so-called acute traumatic cerebral edema. It is very doubt- 
ful if this degree of high intracranial pressure could have been drained 
entirely by the natural means of absorption — possibly for an immediate 
recovery of life but not for an excellent ultimate recovery of normality, 
which was obtained following the operation. The risk of the operation 
was slight compared to the great danger of future impairment — emotionally, 
mentally and physically. • 

The early recovery of hearing is also the usual result of these injuries 
in children, in whom the fracture of the petrous bone does not damage the 
ossicles of the middle ear or the internal ear itself ; the tympanic membrane 
regains its normal appearance very rapidly. 

Case 154. — Acute severe brain injury associated with a linear and also a 
depressed fracture of the left temporo-parietal area and with signs of high 
intracranial pressure ; motor aphasia and right facial weakness. Left 
subtemporal decompression and drainage. Excellent recovery. 

No. 361.— Charles. Ten years. White. School. U. S. 

Admitted March 26, 1915. Polyclinic Hospital. 

Operation March 27, 1915 — 14 hours after admission. Left subtemporal 
decompression and drainage. 

Discharged April 12, 1915 — 14 days after operation. 

Family History. — Parents, brothers and sisters are all right-handed, as is 
the patient. 

Fersonal history negative. 

Present Illness. — While playing in street, the boy was struck and knocked 
down by a taxicab ; no loss of consciousness, or if so, only momentarily, but 
from the time of accident the patient was unable to speak ; brought to the 
hospital in the ambulance. 

Examination upon admission (40 minutes after injury). — Tempera- 
ture, 98.4° ; pulse, 118 j respiration, 28 ; blood-pressure, 110. Conscious, and 
very restless; understands what is said to him, but he is unable to speak, 
although he attempts to do so — making inarticulate sounds; he is able to 
write "you, ' ' "yes " or " no, ' ' but cannot speak the words ; no bleeding from 
nose, mouth or ears; right and left orbital but no mastoid ecchymoses. 
Definite tenderness over the left temporo-parietal area where there is a slight 
depression of the underlying bone of about 2 inches in diameter. Cortical 
paralysis of right side of face is well marked — with drooping of the right 
side of the mouth and the disappearance of the right naso-labial fold ; right 
forehead muscles not involved. No paralysis of the arms or legs. Pupils 
— equal but moderately enlarged and react to light sluggishly. Reflexes : all 



- 



IN NEWBORN BABIES AND CHILDREN 



58S 



\ 



depressed; no Babinski, Oppenheim or Gordon reflexes; abdominal reflexes 
absent. Fundi negative. 

Treatment. — Vigorous shock measures instituted. Within 10 hours (dur- 
ing the night), the condition of the patient improved but the signs of an 
increased intracranial pressure became more and more marked. 

Examination (12 hours after admission). — Temperature, 99.2°; pulse, 
80 ; respiration, 20 ; blood-pressure, 118. Conscious but cannot talk ; points 
to his head and holds it as though having a severe headache. No signs of 
shock. Small hematoma over site of depressed area of bone in the left tem- 
poro-parietal area. Otoscopic examination negative. Right facial paralysis 
of the cortical type persists. 
No weakness of either arm W 
elicited. Pupils — left slightly 
larger than right ; reaction to 
light normal. Reflexes: pa- 
tellar — b o t h exaggerated, 
right possibly more than 
left; double exhaustible left 
ankle clonus but no typical 
Babinski ; abdominal reflexes 
depressed, right possibly 
more than left. Fundi — ret- 
inal veins dilated; nasal 
halves of both optic disks 
obscured by edema. Lumbar 
puncture — slightly blood- 
tinged cerebrospinal fluid 
under high pressure (21 
mm.). X-ray (Doctor A. J. 
Quimby ) — ' ' depressed area 

of bone, 4 cm. in diameter, in left temporal area ; an extensive linear fracture 
of left frontal bone extending backward into left parietal bone and to the 
upper portion of the depressed area" (Fig. 172). 

Treatment. — An immediate subtemporal decompression advised — both 
to lower the general increase of the intracranial pressure and also to remove 
the depressed area of the overlying vault. 

Operation (14 hours after admission). — Left subtemporal decompression : 
usual vertical incision, bone removed, and no complications; bone rather 
thin and extending to the upper part of the squamous bone was a linear frac- 
ture, below which was a depressed area of bone — about V/ 2 inches in diame- 
ter and depressed to a depth of 1 cm. Dura tense and bluish, and upon 
incising it, bloody cerebrospinal fluid spurted to a height of 8 inches ; the 
underlying cortex tended to protrude but did not rupture, as the lateral 
ventricle was now punctured successfully and almost 10 c.c. of clear cerebro- 
spinal fluid was removed, permitting the brain to relax and even to pulsate at 
the end of the operation. No hemorrhage in the cortex itself nor were corti- 
cal lacerations visible. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 42 minutes. 




Fig. 172. — Extensive horizontal linear fracture of left vault 
associated with a depressed fracture, in a patient having a 
high intracranial pressure associated with a motor aphasia and 
right facial weakness. Complete recovery following a left 
subtemporal decompression and removal of bony depression. 



586 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 







Fig. 173. — The seventh day post-operative, showing 
the bilateral orbital ecchymoses and the left subconjunc- 
tival hemorrhage. The usual dressing and head bandage 
securely fastened and "anchored" by several small strips 
of adhesive plaster. 



Post-operative Notes. — Un- 
eventful operative recovery; 2 
hours after operation, this boy 
spoke a few words with difficulty 
and in monosyllables. Within 
36 hours after operation, the 
weakness of the right side of the 
face lessened and the speech was 
improved so that sentences could 
be formed and enunciated 
clearly. On the seventh day 
post-operative, a photograph 
was taken, showing the bandage 
in situ and the orbital ecchy- 
moses (Fig. 173). 

Examination at discharge 
(14 days after operation). — 
Temperature, 98.6°; pulse, 82; 
respiration, 22 ; blood-pressure, 
114. No complaints except "I 
feel a little weak." No facial 
weakness can be demonstrated 
by special tests. Speech is negative ; patient can repeat : "Around the rug- 
ged rock the ragged rascal ran. " " The third red riding artillery brigade, ' ' 
and other test phrases, easily and perfectly; spontaneous sentences also 
enunciated well. Pupils equal and react normally. Reflexes active but 

otherwise negative. Fundi 
— retinal veins slightly en- 
larged, but no obscuration 
of the details of either optic 
disk. Photograph taken at 
discharge, showing the area 
of decompression flush 
with the scalp (Fig. 174). 

Examination (Septem- 
ber 8, 1917—30 months 
after injury) . — No com- 
plaints; "stands near the 
head of the class." Re- 
flexes negative. Fundi neg- 
ative. No signs of facial 
paralysis nor speech 
impairment. 

Last Examination 
(February 8, 1919—47 

Fig. 174. — At discharge on the fourteenth day post-operative; months after iniurv) 

the left decompression area flush with the surrounding scalp; . <i J J ' 

the orbital ecchymoses persisting. No COmplamtS. Reflexes 








IN NEWBORN BABIES AND CHILDREN 587 

negative. Fundi negative. Decompression opening has become small from 
new-bone formation ; pulsation hardly palpable. 

Remarks. — It is doubtful if the depression of the left vault in this patient 
was sufficient to produce the right facial paralysis and the motor aphasia — 
and yet it was situated in the position possible to cause these localizing 
signs of cortical compression. The homolateral pupil was enlarged, however, 
and thus indicating the paralytic effect of the left supracortical lesion — most 
probably the supracortical hemorrhage and more or less localized cortical 
edema — a very common cause for signs of this character. 

It was very interesting to note the signs of an increasing intracranial 
pressure develop as the symptoms and signs of shock subsided. The fact 
that the right facial paralysis and aphasia were observed, even when the 
patient was in shock, would make it appear that the depressed area of the 
left vault was the cause of these signs, since the supracortical hemorrhage 
and edema were later developments as exhibited by the signs of an increasing 
intracranial hemorrhage. 

The excellent immediate and ultimate recoveries to be obtained in these 
children having even severe brain injuries is very gratifying. A longer 
period of time, however, will be necessary before the end-results 
are obtainable. 

Case 155. — Acute severe brain injury associated with an increasing 
intracranial pressure due to a supracortical hemorrhage ; Jacksonian con- 
vulsive seizures. Left subtemporal decompression and drainage. Excel- 
lent recovery. 

No. 372.— Robert. Nine years. White. School. U. S. 

Admitted April 5, 1915 — 35 minutes after injury. Polyclinic Hospital. 

Operation April 5, 1915 — 3 hours after admission. Left subtemporal de- 
compression and drainage. 

Discharged April 25, 1915 — 20 days after operation. 

Family history negative. 

Personal history negative. 

Pressnt Illness. — While playing in the street, patient was knocked down 
by an automobile, striking the left side of his head ; no loss of consciousness ; 
brought to the hospital in a semiconscious, drowsy condition. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 99.4° ; pulse, 78 ; respiration, 22 ; blood-pressure, 124. Rather stupor- 
ous, but answers questions intelligently ; complains of throbbing headache. 
Left side of face and head, especially the left temporo-frontal area, eechy- 
mosed and boggy from the hematomatous infiltration. No bleeding from 
nose, mouth or ears ; ecchymosis of left orbit, but both mastoid areas of nor- 
mal appearance. Pupils — left possibly larger than right and of normal 
reaction to light. Reflexes active, but otherwise negative. Fundi negative. 

Treatment. — Expectant palliative treatment; frequent examinations. 
Within 2 hours, the pulse gradually descended to 60, child became more and 
more stuporous, until there occurred slight convulsive twitchings of the right 
side of the face; then a few moments later, a. convulsion beginning in flie 
right arm, then the right leg and involving the entire right side of the body, 
when the convulsion became a typical general epileptiform seizure. 



588 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Examination (2 hours after admission). — Temperature, 99.8°; pulse, 
58 ; respiration, 16 ; blood-pressure, 128. Semiconscious — being aroused with 
difficulty. Pupils — left pupil slightly dilated, right moderately contracted ; 
sluggish reaction to light. Both eyes turned to the right with nystagmoid 
twitchings. No weakness of the face elicited nor of the right arm or leg. 
Reflexes — patellar active, more marked on right; slight ankle clonus on 
right foot with positive Babinski, Oppenheim and Gordon reflexes ; abdomi- 
nal reflexes depressed but equal. Fundi — dilated retinal veins with an 
edematous blurring of the nasal halves of both optic disks. Lumbar punc- 
ture — bloody cerebrospinal fluid under high intracranial pressure ( approxi- 
mately 20 mm.). 

Treatment. — An immediate left subtemporal decompression and drain- 
age advised. 

Operation (3 hours after admission). — Left subtemporal decompression 
and drainage : usual vertical incision, bone removed, and no complications. 
No line of fracture ascertained. Dura bluish and under high tension ; upon 
incising it, dark blood spurted to a height of 4-5 inches and continued to 
spurt for several seconds. Upon enlarging dural opening, the suffused and 
congested cortex tended to protrude, but it did not rupture owing to the 
rapid escape of much supracortical blood and cerebrospinal fluid; much 
subarachnoid blood in the sulci. An attempt to puncture the lateral ven- 
tricle was not successful in an effort to lower the high cortical tension, which 
was eventually lessened by the drainage of much free blood and excess 
cerebrospinal fluid, so that normal cortical pulsation now became visible. 
No cortical hemorrhage or lacerations ascertained. Usual closure with two 
drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful operative recovery ; much drainage of 
blood continued for 2 days and then the drains were removed. Child be- 
came conscious within 5 hours after the operation and his general condition 
was markedly improved in that the pulse ascended to 74 and no convulsions 
occurred after the operation; during the operation, the child had several 
convulsions similar to the one before operation and always beginning in 
the right side of the face, but none was severe. At the close of the opera- 
tion, extreme restlessness with frequent twitchings of the facial muscles 
appeared ; a restraining sheet was required and also sedatives ; he became 
quiet after iy 2 hours and consciousness returned after 5 hours, when he 
was able to answer questions ; he remembered the circumstances of the 
accident very well. 

Examination at discharge (20 days after operation). — Temperature, 
98.8° ; pulse, 80; respiration, 22; blood-pressure, 118. No complaints other 
than a soreness of the left side of head ; no headache. Perfectly normal 
mentally. No convulsions since the operation. Pupils equal and react nor- 
mally. Reflexes : active but otherwise negative ; no Babinski, although a pos- 
sible tendency to a right Babinski. Fundi — retinal veins slightly enlarged ; 
indistinct blurring of the lower nasal quadrants of both optic disks. X-ray 
report (Doctor A. J. Quimby) — "no line of fracture visible." 

Treatment. — Parents cautioned regarding a non-proteid diet for the 
patient and general hygienic rules. 



IN NEWBORN BABIES AND CHILDREN 589 

Examination (September 4, 1917 — 29 months after injury). — No com- 
plaints; "possibly a little more cranky than the other children." Pupils 
negative. Reflexes active but otherwise negative. Fundi negative. 

Last Examination (April 20, 1919 — 48 months after injury). — No com- 
plaints ; goes to school daily. Decompression area depressed ; normal pulsa- 
tion. Reflexes negative. Fundi negative. 

Remarks. — This case-history is instructive in that the patient was per- 
fectly conscious upon admission to the hospital — in fact, there had been 
no loss of consciousness following the cranial injury — and then he gradually 
exhibited the signs of an increasing intracranial pressure. It is fortunate 
he was not discharged from the hospital at the time of admission, as being 
merely a trivial "bump" on the head — a not infrequent catastrophe. 

The absence of a fracture of the skull to be disclosed, either by the usual 
signs or the rontgenograms, is of no significance other than to emphasize the 
comparative unimportance of the presence or not of a fracture of the skull 
in these patients having brain injuries. 

A lumbar puncture should have been performed upon the patient at the 
time of the first examination, and the presence of blood in the cerebrospinal 
fluid would have impressed us more with the seriousness of the patient's 
condition — from the standpoint that a definite intracranial injury 
had occurred. 

The localized convulsive twitchings and eventually epileptiform seizures 
indicating a left cortical lesion, together with the homolateral dilatation of 
the left pupil indicating the paralytic effect of the left supracortical hemor- 
rhage, whereas the right pupil became constricted as the result of the 
irritative lesion over the right cerebral cortex — these signs are both charac- 
teristic and instructive. 

Case 156. — Acute severe brain injury associated with an increasing intra- 
cranial pressure due to subdural hemorrhage and cerebral edema ; aphasia 
and left facial paralysis. Right subtemporal decompression and drainage. 
Excellent recovery. 

No. 887.— Gustave. Six years. White. School. U. S. 

Admitted Sept. 27, 1917 — 40 minutes after injury. Polyclinic Hospital. 

Operation September 29, 1917 — 40 hours after admission. Right sub- 
temporal decompression and drainage. 

Discharged October 17, 1917 — 18 days after operation. 

Family history negative. Grandfather, mother and one brother are 
left-handed. 

Personal history negative. Patient is right-handed. 

Present Illness. — While playing upon a fire-escape, child fell to the 
ground below — a distance of 45 feet ; immediate loss of consciousness ; 
brought fo the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Tempera- 
ture, 97.8°; pulse, 138; respiration, 30; blood-pressure, 98. Unconscious 
and in severe shock. Eccjvymosis of right orbit. No bleeding from nose. 
mouth or ears; no mastoid ecchymosis. No paralyses ascertained. Pupils 
widely dilated. Reflexes abolished. Fundi negative. 

Treatment. — Vigorous shock measures instituted — especially heated 



59 o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

blankets, hot water bottles, and rectal enemata of hot black coffee. After 
6 hours, the general condition gradually improved, but the signs of moderate 
shock persisted for over 28 hours. 

Examination (30 hours after admission). — Temperature, 99° ; pulse, 78; 
respiration, 78 ; blood-pressure, 116. Semiconscious, although at times 
patient can be aroused sufficiently to turn over, look around, but not to 
answer questions ; he attempts to speak but cannot ; he will, however, make 
signs with his right hand and with his head ; apparently, a definite motor 
aphasia but not a sensory one since he can read questions and also hear them ; 
no astereognosis nor apraxia. Definite left facial paralysis of the cortical 
type (left forehead and upper third of left side Of face not involved). Left 
arm and left leg not appreciably weaker than right arm or right leg. 
Pupils of equal size (right possibly smaller than left) and of normal reaction 
to light. Reflexes — very active but otherwise negative ; no Babinski. Fundi 
— retinal veins full ; nasal halves and temporal margins of both optic disks 
blurred by edema. Lumbar puncture — bloody cerebrospinal fluid under 
high pressure (20 mm.). 

Treatment. — The expectant palliative treatment was continued during 
the night for 8 hours, when an immediate operation was advised as being 
the safer procedure. No rontgenogram was taken before the operation. 

Operation (40 hours after admission). — Right subtemporal decompres- 
sion: usual vertical incision, bone removed, and no complications; in the 
upper posterior portion of the squamous bone was a linear fracture extend- 
ing into it. Dura was very tense and bluish, and upon incising it bloody 
cerebrospinal fluid spurted a distance of 2 cm. The underlying cortex was 
swollen and edematous with multiple punctate hemorrhages in it; much 
bloody cerebrospinal fluid escaped, allowing the cortex to recede and to 
pulsate. No large cortical hemorrhage or laceration observed. Usual 
closure with two drains of rubber tissue inserted. Duration, 35 minutes. 

Post-operative Notes. — Uneventful operative recovery ; child became per- 
fectly conscious within 36 hours after operation, the weakness of the left side 
of face lessened and he was able to talk in monosyllables on the fourth day ; 
sitting up in bed on the sixth day. A rontgenogram taken on the tenth day 
post- operative disclosed a vertical linear fracture of the left parietal bone 
descending into the left squamous bone; the right decompression opening 
with four silver clips in situ is clearly pictured (Fig. 175). 

Examination at discharge (18 days after operation). — No complaints 
other than an occasional headache. Decompression area flush with the scalp ; 
normal pulsation. No facial weakness elicited. No impairment of speech 
but an apparent retardation of thought (possibly natural for the child 
since the parents do not notice it). Hearing negative; otoscopic examina- 
tion negative. Pupils equal and react normally. Fundi — retinal veins 
slightly enlarged; indistinct edematous blurring of lower section of nasal 
margins of both optic disks. 

Treatment. — Parents cautioned regarding general hygienic rules and a 
non-proteid diet ; not to return to school until the spring. 

Examination (May 16, 1918 — 8 months after injury). — No complaints; 
has been attending school since February ; does well in school. Decompres- 



IN NEWBORN BABIES AND CHILDREN 



59i 



sion area slightly depressed and pulsates normally. Reflexes active but 
otherwise negative. Fundi negative. 

Last Examination (April 10, 1919 — 19 months after injury). — No com- 
plaints referable to the head. Operative area depressed and only slight pul- 
sation observed due to narrowing of bony opening from new-bone formation 
about the periphery. Reflexes negative. Fundi negative. 

Remarks. — As the severity of the shock subsided, the gradual onset of 
the left facial paralysis of the cortical type, with the motor aphasia occur- 
ring in a right-handed child but whose brother, mother, and grandfather 
were left-handed, indicated a greater lesion of the right cerebral cortex, 
especially the lower motor area; the ipsolateral constriction of the right 
pupil tended to confirm this, but there were no marked changes in the reflexes 
to strengthen this belief. 
The signs of the high intra- 
cranial pressure made neces- 
sary the operation of decom- 
pression and drainage and 
naturally on the right side, 
although it would have been 
better judgment to have 
operated 8 hours earlier 
instead of permitting the 
patient to run the risk of 
extreme medullary compres- 
sion during the night. 

The motor speech centre 
being on the right side in 
this patient would tend to 
confirm the opinion that at 
least in early life the situa- 
tion of the motor speech 
centre in either cerebral cor- 
tex is one of heredity rather 
than whether the patient 

himself is right- or left-handed ; possibly later in this patient, who was con- 
sidered to be right-handed, the speech centre may have developed in the left 
cerebral cortex, but I doubt it; possibly both cerebral hemispheres were 
equally well developed for the function of speech — one being latent. 

The absence of convulsive twitehings or seizures in this patient cannot 
be explained, except that patients having similar irritative supracortical 
lesions, vary in their resistance to convulsions — whether a greater nerve-cell 
stability or not, is not known; patients having the same irritative cortical 
lesion (as well as can be ascertained at operation or at autopsy) may or 
may not have convulsions and epileptiform seizures. 

After the shock had subsided, the increasing intracranial pressure made 
the operation of decompression and drainage the safer procedure, and it was 
of comparatively no importance whether a fracture of the skull was present 
or not — the operative indications were the same. 




Pig. 175. — Extensive linear fracture of left vault in a patient 
having a motor aphasia and left facial paralysis of the cortical 
central type. Complete recovery following a right decompres- 
sion and drainage of the subdural hemorrhage and cerebral 
edema. 



592 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 157. — Acute severe brain injury associated with a subdural hemor- 
rhage, cerebral edema and with a definite paraplegia ; a marked increase of 
the intracranial pressure. Right subtemporal decompression and drainage. 
Excellent recovery. 

No. 899.— Katherine. Three years. White. U. S. 

Admitted October 7, 1917 — 4 weeks after injury. Polyclinic Hospital. 

Operation October 7, 1917 — 10 hours after admission. Right subtem- 
poral decompression and drainage. 

Discharged October 22, 1917 — 15 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — Four weeks ago, while in the best of health, child fell 
from a baby carriage down upon the brick pavement four steps below — a dis- 
tance of 5 feet, and striking upon the back of the head ; no loss of conscious- 
ness ; child cried, was able to get up and walk away ; she was put to bed, how- 
ever, within one-half hour, and upon the following morning (14 hours 
later), it was found that the child could not move the lower legs below 
the knees ; 24 hours later, both legs were entirely paralyzed. Child remained 
in a semiconscious condition with no marked increase of temperature beyond 
99.8° ; child complained, however, of headaches and was at times very restless. 
Patient has been treated by the expectant palliative method by the family 
doctor during the past 4 weeks since the injury, but the condition of the 
child has remained practically the same ; no convulsions have occurred. 

Examination upon admission (4 weeks after injury). — Temperature, 
99° ; pulse, 80; respiration, 24; blood-pressure, 106. Rather stuporous and 
drowsy; upon being aroused, however, child will answer "yes" and "no" 
and complains of headache. No external evidence of cranial injury except 
a slight tenderness over the occipital prominence. No stiffness nor rigidity 
of the neck and no positive Kernig elicited nor ocular paralyses ; no strabis- 
mus nor nystagmoid twitches ascertained. No orbital nor mastoid ecchy- 
moses. Hearing negative ; otoscopic examination negative. The legs could 
not be moved below the knees and they were definitely weak upon flexing 
and extending the thighs upon the pelvis; an indefinite hypesthesia over 
both legs with no marked signs of demarcation upon approaching the pelvis ; 
this sensory impairment more marked below the knees. (Owing to the 
drowsy and stuporous condition of the child, a careful sensory examination 
could not be made and the accuracy of our findings is doubtful. ) The sense 
of position of the toes apparently impaired. Child would cry upon being 
disturbed and then again fall asleep during these examinations. Pupils 
equal and react to light normally. Reflexes — patellar very much exaggerated 
but equal; inexhaustible ankle clonus and a typical bilateral Babinski; 
abdominal reflexes both absent. Fundi : retinal veins full, tortuous and in 
places buried in edematous retinas ; the details of both optic disks obscured 
by edema — there being present a double papilledema of one diopter swelling. 
Lumbar puncture — straw-colored cerebrospinal fluid under an increased 
pressure (16 mm.) ; 6 c.c. removed for examination; (bacteriological report 
by Doctor Jeffries) — "numerous degenerated red blood-cells; no bacteria 






IN NEWBORN BABIES AND CHILDREN 593 

found"; later report of culture — "negative for bacteria." X-ray report 
(Doctor G. W. Welton) — "no fracture of the skull observed." Urine 
examination negative. 

Treatment. — The presence of the high intracranial pressure with a 
definite weakness of both legs persisting for a period of 4 weeks following 
a cranial injury in spite of the expectant palliative method of treatment, 
indicated the necessity of a mechanical relief of the intracranial condition 
in order to avoid further complications and to give the child her best chance 
of recovery. Considering the injury merely as an incident and not the 
cause of the condition, the case-history is very similar to that of a mild 
meningitis and usually of the tuberculosis type occurring in children, and 
yet the absence of the signs of meningeal irritation and the negative cerebro- 
spinal fluid tended to exclude this possibility. An immediate right subtem- 
poral decompression and drainage was advised, but it was not performed for 
several hours in order to obtain the written consent of the parents; the 
condition of the patient, however, remained practically the same. 

Operation (4 weeks after injury). — Right subtemporal decompression 
and drainage : usual vertical incision, bone removed, and no complications. 
Dura very tense, and upon incising it straw-colored cerebrospinal fluid 
spurted to a height of 8 inches and continued to do so for almost 1 minute ; 
upon enlarging dural opening, the underlying "wet," edematous and con- 
gested cortex tended to protrude, and if a large quantity of cerebrospinal 
fluid had not escaped, it is feared that the cerebral cortex would have rup- 
tured on account of the high intradural pressure ; fortunately, the cortex 
became less tense and finally pulsated feebly at the end of the operation. 
No gross supracortical or cortical hemorrhage observed and no cortical lacera- 
tions — merely a very ' ' wet, ' ' edematous cortex with a reddish blue collection 
of old free blood in the sulci about the cortical veins, where it was becoming 
organized and would later undoubtedly present the picture of a whitish 
induration about the cortical veins, as is observed in the chronic cases of 
supracortical hemorrhage. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 35 minutes. 

Post-operative Notes. — The excellent and almost immediate improve- 
ment observed in this patient is remarkable ; the child appeared much 
brighter upon the day following the operation, became more interested in 
things and no longer complained of headache. She was able to move the toes 
upon the, third day after operation and within a week she could move both 
legs awkwardly. All drainage of straw-colored cerebrospinal fluid ceased 
30 hours after operation and the drains were then removed. The operative 
incision healed per primam. Twelve days after operation, the child was able 
to stand alone and to walk several steps when supported. The parents! now 
insisted upon taking the child home. 

Examination at discharge (15 days after operation). — Temperature, 
98.8°; pulse, 84; respiration, 26; blood-pressure, 110. Patient no longer 
complains of headache. Operative area bulges but pulsates normally. The 
child can now walk several steps without being supported and shows a daily 
improvement; no sensory impairment can be elicited. Hearing negative. 
No ocular paralyses. Pupils equal and react normally. Reflexes — patellar 
38 



594 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






very active but equal ; right exhaustible ankle clonus but no Babinski can be 
elicited, though no plantar flexion can be obtained upon the right foot; 
abdominal reflexes depressed but equal. Fundi — retinal veins enlarged but 
not buried in edema ; nasal margins of both optic disks obscured but the other 
details are distinct. 

Treatment. — Parents cautioned to be very careful regarding the child's 
diet and her general hygienic life ; daily massage for the legs advised. 

Examination (May 18, 1918 — 7 months after operation). — No complaints 
except that the child becomes more easily tired than other children ; no head- 
aches, however, and is apparently well. Decompression area almost flush 
with the surrounding scalp; normal pulsation. No weakness of either leg 
can be elicited; no sensory impairment. Reflexes active but otherwise 
negative. Fundi — retinal veins possibly still larger than normal ; all details 
of both optic disks clear and distinct. 

Last Examination (February 6, 1919 — 16 months after operation). — No 
complaints. "A well girl." Operative area slightly depressed below 
flush of scalp; normal pulsation. Reflexes active but otherwise negative. 
Fundi negative. 

Remarks. — In the absence of a straw-colored cerebrospinal fluid with 
numerous red blood-cells in it, the diagnosis could very easily have bee a 
a mild meningitis and most probably of tuberculous character ; so frequently, 
the history of a preceding cranial injury is obtained from the parents of 
these children, and yet this history of a cranial injury must not be care- 
lessly excluded unless careful examinations do not show, and they did in 
this child, that the cranial injury was not merely an incident but rather the 
cause of the intracranial lesion. A longer period of time, however, must 
elapse before it can be definitely stated that the recovery of normality is a 
permanent one, and that there will be no later signs of the intracranial 
condition — especially epilepsy in its various forms. 

It was rather interesting to observe the persistency of the right ankle 
clonus in its exhaustible form and also the right Babinski, in that no plantar 
flexion could be obtained and these signs upon the right foot controlled by 
the left cerebral hemisphere, which was not decompressed as much as the 
right cerebral hemisphere — the operation being a right subtemporal decom- 
pression. It would appear that the acute cerebral edema was drained more 
from the right cerebral cortex than from the left cerebral cortex, and this 
would naturally be expected — the operation being over the right cerebral 
hemisphere. If the decompression area had remained tense and bulging 
for a period longer than one week, then it probably would have been advis- 
able to have performed a left subtemporal decompression and drainage in 
order that the greatest ultimate recovery could be obtained. 

It is surprising that no convulsive seizures occurred as the result of the 
cortical irritation of the supracortical free blood and the presence of an 
increased intracranial pressure ; it is possible that this complication would 
have occurred later unless relieved as in this patient. 

Case 158. — Acute severe brain injury associated with a fracture of the 
vault and of the base of the skull and with a supracortical hemorrhage and 
an increased intracranial pressure ; left hemiplegia and Jacksonian convul- 



IN NEWBORN BABIES AND CHILDREN 595 

sive seizures. Right subtemporal decompression and drainage. Excel- 
lent recovery. 

No. 933. — James. Seven years. White. School. U. S. 

Admitted December 23, 1917. Polyclinic Hospital. 

Operation December 29, 1917 — 6 days after admission. Right subtem- 
poral decompression and drainage. 

Discharged January 12, 1918 — 13 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in a snow-pile in the street, child was 
knocked down by an automobile ; loss of consciousness for several minutes ; 
brought to the hospital in the ambulance. 

Examination upon admission (10 minutes after injury). — Tempera- 
ture, 97.2°; pulse, 124; respiration, 32; blood-pressure, 98. Semiconscious 
and in severe shock. Slight contusion of the scalp and a diffuse hematoma 
over the right parietal eminence. Profuse bloody discharge mixed with 
cerebrospinal fluid from the right auditory canal; clotted blood observed 
in both external nares. Right orbital and right mastoid ecchymoses. No 
paralyses nor sensory impairments ascertained. Pupils dilated and react 
to light sluggishly. Reflexes all depressed and no Babinski obtained. Fundi 
negative. No further neurological examination was made at this time 
owing to the severe degree of shock. 

Treatment. — Vigorous shock measures instituted — particularly external 
heat by warm blankets and hot water bags, repeated rectal enemata of hot 
black coffee — 3 ounces every 2 hours — and absolute rest and quiet. Within 
8 hours, the child rapidly recovered from the severe condition of shock and 
as the general condition was good with no marked signs of a severe intra- 
cranial lesion, it was believed that the child would make an excellent recovery 
under the expectant palliative treatment alone. No signs of a high intra- 
cranial pressure appeared, although at a lumbar puncture 40 hours after 
admission, bloody cerebrospinal fluid was obtained under an increased 
pressure of 11 mm. ; 12 c.c. were slowly removed as a means of drainage 
therapeutically, and this was again repeated upon the fourth day after 
admission, when the pressure was found to be only 10 mm. and this time 
only 10 c.c. of blood and cerebrospinal fluid were removed. The discharge of 
blood and cerebrospinal fluid from the right ear ceased within 12 hours after 
admission ; an otoscopic examination at this time disclosed a rupture of the 
lower posterior portion of the right tympanic membrane. 

The child remained in a drowsy stuporous condition — although at times 
he was very restless — for a period of 5 days, and as the general condition 
remained good and there developed no definite signs of an increasing intra- 
cranial pressure or other local signs of cerebral impairment, the expectant 
palliative treatment was continued. On the morning of the sixth day after 
admission, the child had a convulsive seizure beginning in the left side of the 
face, then the left arm, and finally the left leg — continuing for almost one 
minute, when a general convulsive seizure occurred and lasted 3 minutes ; 
there was incontinence of both urine and feces and a left hemiparesis 



596 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



was observed following the convulsion. The following examination was 
now made : 

Examination (6 days after admission). — Temperature, 99.4° ; pulse, 80; 
respiration, 22; blood-pressure, 112. Very drowsy and stuporous; upon 
being aroused, however, patient can reply to questions in a confused manner. 
Definite weakness of the entire left side of body — including left side of face 
and of the cortical type of paralysis in that the muscles of the left forehead 
were not involved; no definite sensory impairment elicited (patient was so 
drowsy that the tests of astereognosis and apraxia could not be utilized). 
Pupils — right larger than left and reacts to light possibly more sluggishly 
than left. (At this point of the examination, spasmodic twitchings of the left 

side of the face occurred, 




especially about the left 
side of the mouth and left 
eye; no loss of conscious- 
ness was apparent.) Re- 
flexes — patellar very active, 
left more than right; ex- 
haustible ankle clonus and 
a characteristic left Babin- 
ski, while there was a 
tendency to a right Babin- 
ski ; abdominal reflexes 
could not be elicited. 
Fundi — retinal veins full ; 
nasal half of right optic 
disk obscured by edema to 
a greater degree than in 
the left optic disk. Lum- 
bar puncture — straw-col- 
ored cerebrospinal fluid 
under increased pressure 
(14 mm.). X-ray report 
(Doctor G. W. Welton) — 
"a vertical line of fracture extended downward toward the right mastoid 
area from the right parietal bone in its posterior portion" (Fig. 176). 

Treatment. — In the presence of the Jacksonian convulsive seizure with 
repeated left facial twitchings and an increasing intracranial pressure asso- 
ciated with a left hemiparesis, it was considered advisable to perform a 
right subtemporal decompression and drainage in the hope that the intra- 
cranial condition could be relieved. 

Operation (6 days after admission). — Right subtemporal decompression 
and drainage (primary anesthesia and at intervals) : usual vertical incision, 
bone removed, and no complications. Dura bluish and under moderate ten- 
sion ; upon incising it much straw-colored cerebrospinal fluid escaped, reveal- 
ing a very "wet," swollen, congested cortex; at the upper portion of the 
dural opening, a small layer of supracortical hemorrhage was observed, and 
this currant-jelly clot was removed carefully by means of the spoon-spatula. 



patient 



Fig. 176. — Vertical linear fracture of right vault in 
having a high intracranial pressure with resulting left hemi- 
paresis and Jacksonian convulsive seizures. Excellent recovery 
following a right subtemporal decompression and drainage of 
the supracortical hemorrhage. 



IN NEWBORN BABIES AND CHILDREN 597 

The bulging cerebral cortex now receded and pulsated almost normally. 
No cortical laceration or cortical hemorrhages observed. Usual closure with 
2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Four hours after the operation, a slight convul- 
sive twitching of the left side of the face occurred and this was the last 
spasmodic contraction observed; the child made an excellent recovery in 
that the weakness of the left side of the body had entirely disappeared 
within 50 hours after operation, the incision healed per primam, and no 
further convulsive seizures occurred. 

Examination at discharge (13 days after operation). — Temperature, 
98.8°; pulse, 82; respiration, 24; blood-pressure, 112. No complaints. "I 
am all right." Operative area flush with the surrounding scalp and 
pulsates normally. No weakness of the left side of body can be elicited by 
special tests ; no sensory impairment ; no astereognosis nor apraxia revealed. 
Hearing of right ear impaired ; bone conduction greater than air conduction. 
Pupils of equal size and, of normal reaction. Reflexes : patellar active but 
apparently equal; no ankle clonus nor Babinski; abdominal reflexes — left 
possibly less active than right. Fundi — retinal veins slightly enlarged; 
an indistinct blurring of the lower portions of the nasal margins of both 
optic disks. 

Examination (September 20, 1918 — 9 months after injury). — No com- 
plaints; no convulsive seizures since leaving the hospital and the child 
attended school during the spring. No weakness of the left side of the body 
can be ascertained by special tests. Reflexes active but otherwise negative. 
Fundi negative. Operative area is depressed and slight pulsation palpable. 
Hearing of the right ear less acute than that of left — bone conduction still 
being greater than air conduction. 

Last Examination (May 18, 1919 — 19 months after the injury). — No 
complaints referable to the former head injury; child is doing well in school 
and no convulsion has occurred ; patient is no more irritable or restless than 
the other children. Hearing of right ear possibly less acute than that of 
left ; bone conduction, however, is not greater than air conduction ; otoscopic 
examination of right tympanic membrane is negative, except for a slight 
thickening of its lower posterior portion — possibly a little scar tissue ; no 
retraction of the drum observed. Reflexes active but otherwise negative. 
Fundi negative. 

Remarks. — It is possible if the repeated lumbar punctures and drainage 
had been continued daily, that the complication of convulsive seizures with 
the left hemiparesis could have been prevented and the operation thus 
avoided; as the intracranial pressure, however, did not increase, nor were 
there any signs of it being increased, naturally the lumbar punctures were 
not continued, and it was only when the twitchings of the left side of the 
body occurred and followed by the left hemiplegia, that the severity of the 
condition was recognized and an immediate right subtemporal decompression 
and drainage advised. Although the intracranial pressure was not high — 
it being only 14 mm. at operation — yet the irritative presence of the supra- 
cortical hemorrhagic clot was sufficient to cause the left Jacksonian con- 
vulsions and the subsequent left hemiparesis, and it was this complication 



598 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

that necessitated an early relief of the intracranial condition — and best 
accomplished by a right subtemporal decompression and drainage — the 
operation of choice. 

The excellent recovery of normality with no recurrence of the convulsive 
seizures is very favorable and gratifying, and yet a longer post-operative 
period must elapse before this patient can be considered as beyond all dan- 
ger ; his life should be a well-regulated hygienic one with the avoidance of all 
mental and emotional strain; naturally, the diet and the avoidance of alcohol 
are important. The rapid improvement of the hearing of the right ear is 
characteristic of these cases in children. 

Case 159. — Acute severe brain injury associated with a fracture of the 
vault and with a subdural hemorrhage ; an increasing intracranial pressure. 
Left subtemporal decompression and drainage. Excellent recovery. 

No. 983.— William. Ten years. White. School. U. S. 

Admitted May 20, 1918. Polyclinic Hospital. 

Operation May 21, 1918 — 20 hours after injury. Left subtemporal de- 
compression and drainage. 

Discharged June 5, 1918 — 15 days after admission. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was struck by a boy 
riding a bicycle ; knocked down, striking the cement curbing with the left 
side of his head ; no loss of consciousness and was able to walk to the accident 
room of the hospital with the aid of several boy friends. 

Examination upon admission (30 minutes after injury). — Tempera- 
ture, 97.2° ; pulse, 104 ; respiration, 20 ; blood-pressure, 102. Rather stupor- 
ous and drowsy and in shock. Small contusion of the scalp overlying the 
left fronto-parietal area ; marked tenderness elicited upon palpating this 
area. No bleeding from nose, mouth or ears, but during the examination 
he vomited twice — almost projectile in character. Pupils slightly enlarged 
and react to light sluggishly. Reflexes — all depressed : no Babinski. No 
extensive examination made at this time on account of the condition of 
severe shock — the patient being immediately admitted to a ward bed. 

Treatment. — Vigorous shock measures instituted and the usual expectant 
palliative treatment — especially external warmth and hot water bottles, 
ice-helmet and hot black coffee per rectum every two hours in amounts of 
3 ounces; within 4 hours, the condition of the child improved in that the 
temperature gradually ascended to normal, the blood-pressure to 110, while 
the pulse- and respiration-rates descended more to normal and became more 
regular. After 16 hours, however, the pulse had descended to 72, while 
the child had become more stuporous and almost semiconscious; when 
aroused, the patient would complain of severe headache. 

Examination (18 hours after admission). — Temperature, 101°; pulse, 
70 ; respiration, 20 ; blood-pressure, 116. Very stuporous and difficult to 
arouse. Slight left orbital ecchymosis but no mastoid ecchymoses. No 
paralysis nor marked impairment of sensation ascertained. Otoscopic exam- 
ination negative. Pupils — both small, with little or no reaction to light. 
Reflexes — patellar very active, right possibly more than left ; no ankle clonus 



IN NEWBORN BABIES AND CHILDREN 599 

nor Babinski, but no plantar flexion obtained upon the right foot ; abdominal 
reflexes depressed but equal. Fundi — retinal veins full and slightly tor- 
tuous ; nasal halves of both optic disks obscured by edema and slight blurring 
of the temporal margins of both optic disks. Lumbar puncture — blood- 
tinged cerebrospinal fluid under high intracranial pressure (18 mm.) ; 4 c.c. 
allowed to escape very slowly and only a very small quantity (for fear of 
precipitating medullary complications). X-ray (Doctor G. W. Welton) — 
"an extensive linear fracture of the vault involving the left parietal and 
the left portion of the frontal bone where it terminates in a fork; also a 
linear fracture of the right parietal bone" (Fig. 177). 

Treatment. — The expectant palliative treatment was continued until 
permission for the operation could be obtained from the parents one hour 
later ; condition remained 
practically the same, except 
that the pulse had descended 
to 68 and the child had be- 
become even more stuporous. 

Operation (20 hours after 
injury). — Left subtemporal 
decompression and drainage 
(primary anesthesia and at 
intervals as upon opening the 
dura, etc.) : usual vertical in- 
cision, bone removed, and no 
complications. Dura tense, 
slightly bluish and bulging ; a 
small extradural clot was re- 
moved from the anterior 
upper area of the dural ex- 
posure. Upon incising the 
dura, bloody and straw- 
colored cerebrospinal fluid 

Spurted tO a height Of 5 Fig. 177 « — Two linear fractures of the parietal areas in a 

. ^ ° . patient having a subdural hemorrhage with an increasing 

inches, and Upon enlarging intracranial pressure. Excellent recovery following a left 

.. , . , „ , , , subtemporal decompression and drainage. 

dural opening much tree blood 

and cerebrospinal fluid escaped, permitting the ' ' wet, ' ' edematous cortex to 
recede and to pulsate slightly. No cortical lacerations or hemorrhages ob- 
served — merely a very "wet" and congested swollen brain. Usual closure 
with two drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Child became fully conscious within 8 hours after 
operation, cried for his mother and said, ' ' I feel all right ' ' and ' ' I want to 
go home ' ' ; pulse ascended to 88 and the ophthalmoscope revealed a lessen- 
ing of the obscuration of both optic disks. Profuse drainage of blood-tinged 
and straw-colored cerebrospinal fluid continued for 24 hours and then prac- 
tically ceased, so that both drains were then removed. The operative incision 
healed per primam — all skin sutures being removed upon the sixth day. 

Examination at discharge (14 days after operation"). — Temperature, 
98.8° ; pulse, 80 ; respiration, 24 ; blood-pressure, 112. No complaints except 



Blw 



600 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

for a general soreness over left side of head ; slight tenderness along the lines 
of fracture as revealed by the rontgenogram. Decompression area protrudes 
slightly beyond the flush of scalp; normal pulsation. Hearing negative. 
Pupils equal and react normally. Reflexes active but otherwise negative. 
Fundi — retinal veins slightly enlarged; lower nasal margins of both optic 
disks not entirely distinct. 

Treatment. — Patients advised to restrict the child's activities during 
the coming summer and to observe the usual hygienic rules of diet, sleep 
and daily regulation of the bowels. 

Examination (September 4, 1918 — 4 months after injury). — No com- 
plaints and parents wish to know regarding the advisability of the boy going 
to school. Operative area slightly depressed beneath the flush of scalp and 
pulsates normally. No retardation mentally nor an emotional instability 
elicited. Reflexes active but otherwise negative. Fundi negative. Parents 
advised to permit the boy to attend school, but to caution him and the teacher 
regarding a too strenuous exertion — no examinations for at least a year. 

Last Examination (May 14, 1919 — 12 months after injury). — No com- 
plaints and child has done well in school ; no headache and no visual impair- 
ment, Reflexes active but otherwise negative. 

Remarks. — The presence of an increasing intracranial pressure to the 
height of 18 mm. as registered by the spinal mercurial manometer, with an 
increasing stupor and the definite signs of an intracranial pressure as 
disclosed by the ophthalmoscope — these findings made advisable the early 
mechanical lowering of this increasing intracranial pressure, whether due to 
hemorrhage or an excess amount of cerebrospinal fluid. The necessity for the 
operation is less indicated in children than in adults — all other factors 
being the same, but it is in this type of patient wiiere the intracranial 
pressure is rapidly increasing that it is most dangerous to delay the operation 
of decompression until the extreme signs of medullary compression, such as 
a very much lowered and irregular pulse- and respiration-rate, profound 
unconsciousness and a height of intracranial pressure, even to the degree of 
papilledema or even measurable swelling of the optic disks and an increased 
pressure of the cerebrospinal fluid to 20 mm. and even higher. It is in 
these patients having a high intracranial pressure that repeated lumbar 
punctures and drainage therapeutically would be most dangerous for fear 
of producing an acute medullary compression and its subsequent medul- 
lary edema. 

The unimportance of the presence or not of a linear fracture of the vault 
in this case is well demonstrated ; if the underlying dura had been torn, it 
would have been possible for much of the subdural hemorrhage and excess 
cerebrospinal fluid to have escaped into the extracranial tissues of the scalp 
to form a hematoma, and in this manner the increasing intracranial pres- 
sure might have been sufficiently lowered to have avoided the necessity of an 
operation and therefore the fracture in itself would have been a favorable 
occurrence in this case; as it was, however, the presence of the fractures 
was merely an incident rather than an important factor in the condition, 
both from the standpoint of diagnosis and of prognosis, and especially in 
the treatment of the intracranial condition. 



IN NEWBORN BABIES AND CHILDREN 60 1 

Case 160. — Acute severe brain injury associated with a fracture of the 
vault and with an extradural hemorrhage due to a rupture of the middle 
meningeal artery; a definite increase of the intracranial pressure. Left 
subtemporal exploration and ligation of the middle meningeal artery. Excel- 
lent recovery. 

No. 1013. — Morris. Nine years. White. School. U. S. 

Admitted September 28, 1918. Polyclinic Hospital. 

Operation September 29, 1918 — 17 hours after admission. Left subtem- 
poral exploration. 

Discharged October 13, 1918 — 15 days after injury. 

Family history negative. 

Personal history negative. Patient and relatives are all right-handed. 

Present Illness. — While crossing the street, patient was struck by an auto- 
truck and knocked down ; carried into a drug-store in a semiconscious con- 
dition ; brought to the hospital in the ambulance. 

Examination upon admission (45 minutes after injury). — Tempera- 
ture, 98.6° ; pulse, 130 ; respiration, 30 ; blood-pressure, 104. Rather stupor- 
ous and in mild degree of shock. Over the left temporo-parietal area near 
the anterior portion of the left parietal crest is a tense fluctuating hematoma 
of the size of a lemon ; this entire area very tender upon palpation. Left 
orbit ecchymosed and multiple contusions over the left side of the scalp and 
the body. No paralyses or marked sensory impairments ascertained. No 
bleeding from the nose, mouth or ears ; no mastoid ecchymoses. Pupils equal 
and react normally to light. Reflexes — present and equal; no Babinski. 
Fundi negative. No extensive examination performed at this time for fear 
of prolonging and even increasing the general condition of shock. 

Treatment. — Expectant palliative. Within two hours, the general con- 
dition had so improved in that the pulse- and respiration-rates had descended 
to 96 and 24, respectively, that a lumbar puncture was performed and clear 
cerebrospinal fluid was obtained under only a slightly increased pressure 
(9 mm.) and 10 c.c. were slowly withdrawn. The hematoma over the left 
parietal crest, having become more tense and even larger than upon admis- 
sion, it was considered advisable to aspirate it through a clean area of the 
scalp and with careful asepsis ; almost 3 ounces of pure blood were removed 
and a tight bandage was applied. Within 6 hours, however, the hematoma 
had refilled and it was again aspirated and almost 4 ounces of pure blood 
were this time removed and another tight bandage applied. The X-ray 
report (Doctor G. W. Welton) was "a wide linear fracture extending 
obliquely from the left parietal crest downward and forward into the left 
frontal bone just above the left external angular process" (Fig. 178). and 
it was therefore feared that the left middle meningeal artery had been torn 
by the line of fracture and that the resulting extradural blood was escaping 
through the line of fracture into the extracranial tissues of the scalp to form 
the hematoma; this belief was further strengthened by the fact that the 
hematoma again became tense and of its former large size for the third time 
within another period of 4 hours. 

Examination (15 hours after admission). — -Temperature, 99.6°; pulse, 
88 ; respiration, 24 ; blood-pressure, 112. Conscious but drowsy ; talks ration- 



602 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

ally and answers questions with no mental or emotional confusion. Hema- 
toma has become tense again for the fourth time and very tender. Left 
orbit closed by edema. A slight weakness of the right side of the face and 
of the right arm has appeared within the last four hours ; no definite impair- 
ment of the right leg ; no sensory disturbance. No aphasia elicited by special 
tests. Hearing negative. Otoscopic examination negative. Pupils — left 
possibly larger than right ; reaction to light normal. No ocular paralyses ; 
no nystagmus. Reflexes — patellar exaggerated, right more than left; no 
ankle clonus but suggestive right Babinski; abdominal reflexes depressed 
but no inequality elicited. Fundi: retinal veins enlarged — left possibly 
more than right; nasal margins of both optic disks and nasal half of left 
optic disk blurred by edema. Lumbar puncture — clear cerebrospinal fluid 

under increased pressure 
(14 mm.). 

Treatment, — For fear 
*>. that an extradural hemor- 

rhage was compressing the 
left cerebral cortex, a left 
subtemporal exploration was 
& advised to be performed 
immediately. 

Operation (17 hours 
after admission ) . — Lef t 
subtemporal exploration, re- 
moval of extradural hemor- 
rhage and ligation of left 
fB^^B^^wBm middle meningeal artery: 






Fig. 178.— A wide extensive linear fracture of the left vault, usua l Vertical mClS10H, 

causing a rupture of the left middle meningeal artery. Excel- removal of bone, and no COU1- 
lent recovery following a left subtemporal exploration, removal 

of extradural hemorrhage and the ligation of the left middle plications ; Upon enlarging 

meningeal artery. , . ' 

the bony opening as made 
by the Doyen perforator and burr, a dark currant-jelly extradural clot 
with much free red blood extruded through the bony opening under high 
pressure and upon enlarging this opening, a large amount of blood-clot of 
almost 6 ounces was removed, permitting the underlying depressed dura 
to rise and thereby relieving the compression of the underlying cerebral 
cortex. The middle meningeal artery was ligated by a silver clip to prevent 
more bleeding. The dura itself was of normal appearance and pulsated 
normally, and therefore it was not considered advisable to open it. After 
all the extradural blood-clot) had been removed, the usual closure was made 
with 2 drains of rubber tissue inserted down to the dura. It was now 
noted that the hematoma, which was situated anterior to the operative 
incision, had become much smaller and less tense due undoubtedly to much 
of its bloody contents having been removed when the extradural hemor- 
rhage was evacuated during the operation — its blood having returned intra- 
cranially through the underlying line of fracture. Duration, 50 minutes. 
Post-operative Notes. — An uneventful recovery; the weakness of the 
right arm and of the right side of the face entirely disappeared within 6 



IN NEWBORN BABIES AND CHILDREN 603 

hours after the operation and the suggestive Babinski also could not be ob- 
tained at that time. The general condition of the child immediately 
improved; the wound healed per primam — all skin sutures having been 
removed upon the fifth day after operation. 

Examination at discharge (14 days after operation). — Temperature 
98.8° ; pulse, 80 ; respiration, 24 ; blood-pressure, 112. No complaints except 
the soreness over the left side of the head. The operative incision has healed 
perfectly ; no protrusion but a normal pulsation is visible. The hematoma 
has entirely disappeared. No paralysis of the right side of the face or right 
arm ascertained; no sensory impairment nor astereognosis. Pupils equal 
and react normally. Reflexes active but otherwise negative. Fundi — 
retinal veins possibly enlarged; all details of both optic disks clear 
and distinct. 

Last Examination (May 16, 1919 — 9 months after injury). — No com- 
plaints; patient has done well in school since January — the third month 
after the injury. Operative area depressed ; slight pulsation palpable. No 
weakness or awkwardness of the right side of the body ; no speech impair- 
ment. Reflexes active but otherwise negative. Fundi negative. 

Remarks. — It is possible that repeated aspirations of the hematoma 
overlying the site of the fracture of the vault and the extradural hemorrhage 
could have drained this extradural hemorrhage successfully, if the blood had 
not gradually coagulated and formed an extradural clot; possibly more 
frequent aspirations of the hematoma would have lessened and delayed 
the formation of this clot, and yet the bleeding from the left middle menin- 
geal artery was so profuse that it is very doubtful whether this method of 
treatment would have been eventually satisfactory. The clear cerebrospinal 
fluid under an increasing pressure and the presence of a fracture of the 
left vault in the vicinity of the left middle meningeal artery, together with 
the localizing signs of weakness of the right arm and of the right side of the 
face and the other neurological signs, made the diagnosis of an extradural 
hemorrhage a most probable one. The absence of aphasia or paraphasia is 
interesting, especially in a patient who is right-handed and whose ancestors 
and relatives are all right-handed ; how the motor speech area escaped being 
compressed sufficiently to cause an impairment of speech is difficult to 
conceive, especially since the extradural hemorrhage lay directly over the 
posterior portion of the third left frontal convolution. It is possible that 
an aphasic impairment would have occurred if the operation had been 
delayed several hours longer. 

The rapid subsidence of the signs of the intracranial lesion and of the 
cerebral impairment was most impressive following the operation and the 
excellent recovery of normality of this patient is gratifying, as it was 
feared at the time of the operation that too long a delay had been permitted 
and that an earlier operation would have been more advisable. 

Case 161. — Acute severe brain injury associated with high intracranial 
pressure due to supracortical hemorrhage and with no fracture of the vault 
of the skull ascertained. Bilateral decompression and drainage. Exeel- 
lent recovery. 

No. 881.— Murray. Ten years. White. School. U. S. 



6o 4 DIAGNOSIS AND TREATMENT OP BRAIN INJURIES 

Admitted August 13, 1917. Polyclinic Hospital. 

Operation August 17, 1917 — 4 days after admission. Bilateral decom- 
pression and drainage. 

Discharged September 14, 1917 — 27 days after operation. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was knocked down 
by an automobile; immediate loss of consciousness; brought to the hospital 
in the ambulance. 

Examination upon admission (one hour after injury). — Temperature, 
98°; pulse, 132; respiration, 32; blood-pressure, 104. Unconscious and in 
severe shock. Small hematoma over the vertex of the vault. Xo bleeding 
from nose, mouth or ears ; no orbital nor mastoid ecchymoses. No paralyses 
ascertained. Pupils widely dilated and do not react to light. Reflexes all 
abolished. Fundi negative. 

Treatment. — Vigorous shock measures instituted, especially heated 
blankets, hot water bottles and rectal enemata of hot black coffee ; absolute 
quiet — no further examination being made until patient should recover 
from this extreme condition of shock. After 48 hours, patient gradually 
emerged from the shock. 

Examination (60 hours after admission). — Temperature, 99.2°; pulse, 
90; respiration, 22; blood-pressure, 114. Semiconscious, but cannot be 
aroused sufficiently to answer questions. Left orbital but no mastoid ecchy- 
mosis; otoscopic examination negative. Bimanual examination of the vault 
negative. No paralysis elicited. Pupils of moderate size, equal, but react 
to light sluggishly. Reflexes — patellar exaggerated and equal; no ankle 
clonus but suggestive double Babinski ; abdominal reflexes absent. Lumbar 
puncture — bloody cerebrospinal under increased pressure (20 mm.). 
X-ray (Doctor Gr. W. Welt on) — "no fracture visible." 

Treatment. — Expectant palliative treatment continued for 24 hours 
longer, but as the signs of an increasing intracranial pressure progressed 
so that a double papilledema of 1 diopter was revealed in the fundi and 
a second lumbar puncture registered a pressure of 24 mm. and the pulse had 
also descended to 70, therefore an immediate right subtemporal decompres- 
sion was performed. 

Operation (4 days after admission). — Right subtemporal decompression 
(primary anesthesia) : usual vertical incision, bone removed, and no com- 
plications. Dura was very tense and somewhat bluish, and upon incising it 
bloody cerebrospinal fluid spurted a distance of 3 feet, revealing a very ede- 
matous cortex under very high pressure so that it protruded and ruptured 
to a depth of 1 cm. ; no pulsation visible. An attempt to tap the right ven- 
tricle was unsuccessful. No evidence of any large blood-clot, but several 
punctate hemorrhages were present in the underlying cortex which had the 
appearance of being "water-logged." Much difficulty encountered in 
attempting to close the incision owing to the bulging of the cerebral cortex 
which did not pulsate. An immediate left subtemporal decompression was 
considered advisable. Usual closure with 2 drains of rubber tissue inserted. 

Left subtemporal decompression : usual vertical incision, bone removed, 



IN NEWBORN BABIES AND CHILDREN 



605 



and no complications. Dura was bluish and very tense, and upon incising 
it much bloody cerebrospinal fluid welled out, allowing the swollen cortex to 
bulge and then to pulsate for the first time. Cortex was in good condition, 
except in lower part of the operative field where it appeared to have been 
contused. No evidence of gross blood-clot was found: occasional punctate 
hemorrhage in the cortex was visible. At the end of the operation, the brain 
pulsated almost normally. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 90 minutes. 

Post-operative Notes. — Child had a very stormy convalescence ; semicon- 
scious and irrational for almost one month, requiring an unusual amount of 
sedatives; temperature remained about 102°. Left eye "cleared up" one 
week after the operation,while the right eye continued to be blurred by edema 
one week longer. The general condition 
of the patient gradually improved, he 
became less and less irrational after the 
signs of an increased intracranial pres- 
sure subsided, so that he could be promptly 
discharged. A photograph was taken on 
the eighth day post-operative ; the left or- 
bital ecchymosis is still visible (Fig. 179). 

Examination at discharge (27 days 
after operation). — Temperature, 98.2°; 
pulse, 80; respiration, 24; blood-pressure, 
116. Perfectly conscious; apparently 
retarded slightly in thought and expres- 
sion, but parents say "he was always that 
way." Occasional dull headache; other- 
wise feels well. Both operative areas 
flush with the surrounding scalp ; normal 
pulsation. Hearing negative. Pupils 
equal and of normal reaction. Reflexes 
active but equal. Fundi — retinal veins 
enlarged ; lower nasal quadrant especially 
of right optic disk, slightly obscured by edema. 

Treatment. — Parents cautioned to keep the boy from all active mental 
and physical exercise ; not to attend school for one year. 

Examination (September 6, 1918 — 13 months after injury). — No com- 
plaints except an occasional headache of mild severity. Decompression 
areas slightly depressed, normal pulsation. Reflexes active but otherwise 
negative. Fundi — retinal veins possibly larger than normal; no blurring 
of the details of the optic disks. Patient is permitted to begin school next 
week but must not study much ; if the headaches should occur, then lie must 
remain away from school another year. 

Last Examination (April 20, 1919 — 19 months after injury). — Xo com- 
plaints; teacher states, "Murray can do his work as well as the other boys." 
He is possibly more unstable emotionally than formerly. Operative sites 
depressed; pulsation not so evident. Reflexes active but otherwise negative. 
Fundi — retinal veins of normal size; details of the optic disks clear. 




Fig. 179. — The eighth day post-operative of 
a patient having an extreme intracranial 
pressure due to a large supracortical hemor- 
rhage, and not associated with a fracture 
of the skull; bilateral decompression and 
drainage. Excellent recovery. 



606 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Remarks. — The necessity of performing a bilateral decompression in 
children having brain injuries is much less frequent than in adults, although 
in these latter patients it is not over 5 per cent, of the operated patients 
that the intracranial pressure is so high that one decompression alone will 
not suffice to relieve the pressure satisfactorily; in children, the percentage 
of these patients requiring a bilateral decompression is not over 3 per cent. — 
at least, this is the percentage in this series of patients. Children are able 
to resist more successfully by adaptation a higher increased intracranial 
pressure than is possible for adults, and they also can absorb by natural 
means a larger amount of intracranial hemorrhage and edema, so that if the 
operation of decompression and drainage is necessary, usually one operation 
alone suffices. 

A longer period of time must elapse in this case before it can be stated 
that the end-result is an excellent one; it is difficult to conceive that this 
patient will not be impaired in some way — mentally and especially emotion- 
ally, and also there is the great danger of epileptiform seizures should dis- 
sipation in any form occur later, particularly alcoholism. 

It is fortunate in this patient that a right subtemporal decompression was 
performed first, since the rupture of the underlying cortex might have 
permanently injured the motor speech centre if the operation had been per- 
formed on the left side first. In patients having high intracranial pressure, 
it is better judgment always to operate upon the side opposite to the supposed 
speech centre, unless the signs indicate a local lesion in this area ; in selected 
cases of very high intracranial pressure, the first operation should be per- 
formed on the opposite side (the safer procedure), and then the second 
operation over the site of the lesion. 

E. Acute severe brain injuries associated with varying degrees of intra- 
cranial lesions. Death. Autopsy. 

Case 162. — Acute severe brain injury not associated with a fracture of 
the skull, but with severe initial shock and no intracranial hemorrhage — 
merely a ' ' wet, ' ' edematous condition of the brain ; no signs of an increased 
intracranial pressure. No operation. Death from shock; autopsy. 

No. 80. — Veronica. Ten years. White. School. U. S. 

Admitted September 24, 1914. — 40 minutes after injury. Polyclinic 
Hospital. Referred by Doctor Alexander Lyle. 

Died September 24, 1914 — 9 hours after admission. Shock. 

Family history negative. 

Personal history negative. 

Present Illness. — While crossing the street, patient was knocked down 
by an automobile ; unconscious for several minutes but became semiconscious 
en route to the hospital in the automobile. 

Examination upon admission (40 minutes after injury). — Temperature, 
97.6° ; pulse, 130; respiration, 30; blood-pressure, 90. Semiconscious; can- 
not be aroused to answer questions ; very restless. Extensive abrasions and 
contusions of entire forehead ; multiple contusions of head and entire body. 
Slight bleeding from the nose and both ears ; no cerebrospinal fluid observed ; 
double orbital but no mastoid ecchymoses. No paralyses ascertained. Pupils 
slightly enlarged and react to light sluggishly. Reflexes — patellar difficult to 



IN NEWBORN BABIES AND CHILDREN 607 

elicit; no ankle clonus bnt suggestive right Babinski; abdominal reflexes 
absent. Fundi negative. No extensive neurological examination made at 
this time in the hope that with the vigorous treatment of shock, together with 
the expectant palliative treatment, that the condition of the patient would 
be improved and then a more thorough examination would be possible. 

Treatment. — Vigorous shock measures instituted — external heat by 
heated blankets and hot water bottles, hot black coffee per rectum, small 
repeated doses of codeine (grains %), hypodermically to control the rest- 
lessness, absolute quiet, etc. Within 6 hours after admission, the patient 
did show some signs of improvement in that the temperature became 98.2° 
and the blood-pressure ascended to 94, but the pulse- and respiration-rates 
remained over 140 and 38, respectively, becoming weaker and more difficult 
to auscultate; the patient one hour later suddenly became worse in that 
the temperature descended to 97.8° and the blood-pressure to 82, and the 
patient died, 9 hours after admission, from the condition of typical shock 
following a severe cranial injury. 

Autopsy. — No fracture of the skull found. Both tympanic membranes 
were intact and the source of bleeding from the ears was in several small 
lacerations of the outer portion of both external auditory canals (illustrating 
the value of careful otoscopic examinations in all of these patients having 
a bloody discharge from the ear and yet no cerebrospinal fluid is observed). 
No intracranial hemorrhage found, but on the contrary the brain was rather 
pale and anemic and the cortical vessels small. Much cerebrospinal fluid 
was in the basal fossa? and the cerebral tissues were "wet" and edematous, 
but not to the extent of being "water-logged" as in an acute cerebral edema. 
Ventricles were negative. 

Remarks. — The signs of this patient as exhibited following her admis- 
sion to the hospital were all those of severe initial shock following the cranial 
injury, and during the first 6 hours they were no more severe than fre- 
quently occur in many patients who make excellent recoveries. It was 
thought at the time that this patient would recover from the severity 
of the shock and especially since the patient was a child, as children can 
endure the shock following cranial injuries much better than can adults. 
It would seem, however, that although this patient struggled to overcome 
the effects of the severe shock, her powers of resistance and especially her 
vasomotor mechanism were not sufficient to withstand the prolonged effect 
of the condition of shock. 

The treatment of the shock in these patients is most effective in the use 
of external heat, enemata of hot black coffee and absolute rest and quiet — 
frequently repeated small doses of morphia in adults and codeine in children 
hypodermically being most valuable. 

The absence of all signs of an increased intracranial pressure, as dis- 
closed by the ophthalmoscope, would undoubtedly have been confirmed, if a 
lumbar puncture had been performed; no attempt was made to perform 
a lumbar puncture, however, on account of the severity of the shock and the 
autopsy findings of cerebral anemia and a general mild edema of the brain 
would indicate its absence. 

It is rather unusual that bleeding from both ears should occur in the 



6o8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

same patient and yet there be present an intact tympanic membrane; 
although there was no cerebrospinal fluid observed, yet that observation 
does not exclude a fracture of the base of the skull with a resulting lacera- 
tion of the tympanic membrane. The value of careful otoscopic examinations 
in all patients having cranial injuries — but after the aural discharge has 
ceased so that the danger of infection is practically nil, is well illustrated in 
this patient, and no patient should be considered as having a condition of 
brain injury with a fracture of the skull merely upon the observation that 
blood was discharged from either ear — and no otoscopic examination made. 

Case 163. — Recent severe brain injury following an apparently trivial 
* ' bump ' ' upon the head associated with a supracortical hemorrhage and with 
definite localizing signs. No cranial operation. Death ; autopsy ; sarcomatosis. 

No. 64. — David. Four and a half years. White. U. S. 

Admitted July 12, 1914 — 5 months after cranial injury. Polyclinic Hos- 
pital. Referred by Doctor B. Van D. Hedges, Plainfield, N. J. 

Died July 14, 1914 — 8 hours after abdominal operation. 

Family history negative ; two brothers and one sister well and strong. 

Personal history negative; always well and strong; no diseases 
of childhood. 

Present Illness. — Five months ago (February 17, 1914), while playing 
with his brothers, patient fell upon the ground, striking his head ; apparently 
no loss of consciousness ; no bleeding from ears or nose. Upon rising, patient 
seemed rather drowsy ; he was seated in a chair, and one-half hour later, it 
was noticed that the patient could not move his right leg and within another 
hour, the right arm became weak and paralyzed ; no paralysis of right side of 
face observed ; no aphasia, though a definite slurring of words was noticed. 
No fever; pulse and respirations were normal; no nausea or vomiting. 
Within 6 hours, the paralyses became less marked, first in the arm and then 
in the leg, so that within 36 hours the child was apparently normal. Three 
weeks later (March 6, 1914), after being in as good health as before the 
"bump" on the head, the child was observed by the parents to be limping 
on the right leg, and within 4 hours the right leg was paralyzed and the 
right arm was much weaker than the left arm; no paralysis of the face. 
Some drowsiness. No general convulsions, but the fingers of the right hand 
twitched infrequently. No nausea or vomiting; appetite good; bowels 
regular daily. 

First Examination (March 7, 1914 — 4 months ago). — Patient examined 
in consultation with Doctor Hedges and Doctor Robert Abbe. Temperature, 
99.4° ; pulse, 88 ; respiration, 24. Well-nourished child ; perfectly conscious. 
Heart and lungs negative. Liver extended % inch below costal margin and 
it was not considered abnormal for a child of 4% years of age. Spleen just 
palpable. No abdominal pain or tenderness. The paralysis had already les- 
sened so that the right arm was almost normal, but the right leg was definitely 
weaker than the left leg ; no facial paralysis. We were unable to induce the 
child to talk, although the parents said he had been talking normally before 
our examination. No disturbance of sensation. No ocular paralyses other 
than possibly a slight weakness of the left external rectus. No nystagmus. 
Reflexes : patellar — right greater than left ; no ankle clonus but right Babin- 



IN NEWBORN BABIES AND CHILDREN 609 

ski was elicited ; right abdominal reflexes depressed. Fundi — moderate dila- 
tation of the retinal veins; definite blurring of the nasal margins of the 
optic disks — left possibly greater than right. 

Treatment. — The tentative diagnosis was a small cortical hemorrhage, a 
possible tuberculoma or a tuberculous meningitis of mild severity ; the blood 
and cerebrospinal fluid by lumbar punctures were advised in order to 
obtain a Wassermann test and cell count (these were later returned nega- 
tive). Within 36 hours after this second onset of paralysis, the child grad- 
ually became normal, and it remained in its normal good health until July 7, 
1914 — 4 months after the second attack. of paralysis; the parents then 
observed that the child was not moving the right side of its face, and upon 
examination in my office on July 11, 1914 (4 days later), I found an almost 
total right facial paralysis (central in origin), and a slight weakness of the 
right arm ; the right leg was apparently normal. Some blurring of speech. 
No sensory disturbance. Pupils — left smaller than right. No ocular paraly- 
sis. No nystagmus. Reflexes : right greater than left ; no ankle clonus but 
a tendency to a right Babinski reflex ; abdominal reflexes — right less active 
than left. Fundi — slight dilatation of the retinal veins, and the blurring 
along the nasal margins, especially of the left optic disk, still persists. Heart 
and lungs were negative, but during the routine examination of the abdomen, 
however, a firm nodular mass — the size of an orange — was palpable in the 
upper right hypochondrium ; it was evidently in the liver, which extended 
down to the level of the umbilicus; no jaundice was present and apparently 
no digestive disturbances. The spleen and right kidney were just palpable 
and apparently normal. 

Examination upon admission (July 12, 1914 — 5 months after the 
cranial injury). — The neurological examination was the same as at the pre- 
ceding examination. The laboratory tests of the blood, cerebrospinal fluid, 
urine and stool, including the tuberculin and luetin tests, were made and 
were all negative. Doctor J. P. Grant then made an exploratory incision 
through the right rectus muscle and removed a hard fibrous tumor, the size 
of a large fist, from the liver ; the pathological report was a small-round-celled 
sarcoma. The child died 8 hours after operation. 

Autopsy. — Abdomen : not only sarcomatous masses in the liver, but also 
extensive involvement of the lymph-nodes of the lesser and greater curva- 
tures of the stomach and in the mediastinum; sarcomatous enlargement 
of the head of the pancreas, and sarcomatous nodules in the right kidney ; 
the adrenals were normal. 

Brain : a bluish hemorrhagic clot, % inch in thickness, was situated in 
the pia-arachnoid over the precentral area of the left motor cortex, which 
was very ' ' wet ' ' and edematous, and it extended forward into the left frontal 
lobe and from the longitudinal fissure downward almost to the left Sylvian 
fissure; the posterior portion of the third left frontal convolution was par- 
tially covered. Careful sectioning of the brain did not reveal any sarco- 
matous degeneration or any other lesion. No fracture of the vault or of 
the base of the skull was revealed. 

Remarks. — This case is most unusual and the possibilities of diagnosis 
were many. A "bump on the head" — not worse than is frequently received 
39 



6io DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

by children — followed by paralysis, which improves only to return 3 weeks 
later ; another rapid recovery and then a return of paralysis 4 months later. 
The appearance of a rapidly growing tumor in the liver, which proves at 
operation to be a small round-celled sarcoma with many metastases, and yet 
the brain is not involved — only the supracortical hemorrhage of the early 
' * bump ' ' being ascertained with no fracture of the base or of the vault of the 
skull — which is not uncommon. 

The signs of a mild increase of the intracranial pressure associated with 
a weakness of different portions of the right side of the body and a slight 
paraphasia (in a child who was right-handed and whose parents were also 
right-handed), indicated a lesion of the left motor cortex — and a lesion of 
varying character associated with cortical edema, then convulsive twitchings 
of the fingers of the right hand pointed to an irritative cortical lesion, and 
especially in the presence of the ipsolateral pupillary contraction of the left 
eye. It is surprising, however, that the convulsive twitchings did not persist 
unless the localized cortical edema about the hemorrhagic area was of such 
a temporary character that a localized epileptiform seizure was thereby 
avoided ; at the time of the extensive paralysis of the right leg and of the 
right arm, the localized cerebral edema must have been severe. 

If it had not been for the complication of the malignant tumor formation, 
it would have been possible for the patient alone and without an operation 
to have " taken care of" the supracortical lesion of hemorrhage and cortical 
edema, but the natural means of absorptive powers and the general resist- 
ance were so lowered by the sarcomatous process that the recovery from the 
intracranial lesion was not the usual normal one. 

Case 164. — Acute severe cranial injury associated with a compound 
linear fracture of the right vault ; later, definite weakness of the left side of 
body and with an increased intracranial pressure. Local operation at the 
site of the laceration of the scalp and the underlying fracture. Brain abscess 
and meningitis. Death ; autopsy. 

No. 972.— Rudolph. Five years. White. U. S. 

Admitted February 14, 1918 — 14 daj T s after cranial injury. Coney 
Island Hospital. Referred by Doctor R. S. Green. 

Operation March 8, 1918 — 24 days after admission. Local operation at 
the site of compound fracture. 

Examination for the first time in consultation — March 16, 1918- — 45 days 
after injury. 

Died March 18, 1918 — 10 days after operation and 47 days after injury. 
Brain abscess and purulent meningitis. 

Family history negative. 

Personal History. — Two weeks before admission to the Coney Island 
Hospital, the patient was struck upon the right side of the vault by an iron 
fragment following a stove explosion in the kitchen of his home; right 
parieto-frontal area lacerated; loss of consciousness for several minutes; 
wound sutured by family doctor and patient remained at home in bed for 
one week, when increasing headaches and loss of appetite caused the parents 
to remove the child to a sanitarium ; within the following week, the headaches 
increased in severity and a definite weakness of the left side of the body 



IN NEWBORN BABIES AND CHILDREN 611 

appeared and the child was finally transferred to the Coney Island Hospital, 
where it was found that the child was stuporous, having a temperature of 
100.8° ; a definite weakness of the left side of the body was present with 
increased reflexes upon the left side ; otherwise, the patient was in fair con- 
dition and remained so until March the eighth (24 days after admission), 
when the paralysis of the left side became more marked, the temperature 
ascended to 102.6° and the general condition of the patient appeared to 
be worse; the laceration over the right fronto-parietal area was enlarged 
and by means of rongeurs the underlying fracture was widened and explored 
carefully with a small probe ; no signs of infection ascertained ; the dura was 
apparently not torn and was not opened at the operation. Patient, however, 
progressively became worse until the time of the following consultation : 

Consultation (March 16, 1918 — 45 days after the injury). — Tempera- 
ture, 104.8°; pulse, 132; respiration, 30; blood-pressure, 108. Profoundly 
unconscious and moribund. Laceration of scalp apparently healed per 
primam. Neck — slightly stiff and a suggestive positive double Kernig. 
Complete left hemiplegia and a definite weakness of both the right arm and 
right leg. Otoscopic examination negative. Pupils — right widely dilated 
and immobile ; left slightly dilated with sluggish reaction to light. Reflexes 
— all reflexes abolished, both skin and deep reflexes. Fundi — retinal veins are 
tortuous and dilated ; slight edematous blurring of the nasal margins of both 
optic disks; otherwise negative. Lumbar puncture — turbid cerebrospinal 
fluid under increased pressure (approximately 14 mm.) ; "staphylococci." 

Treatment. — The child being moribund and the condition one of menin- 
gitis most probably of a diffuse character, it was considered advisable merely 
to continue the expectant treatment and the use of the antimeningitic sera. 
The condition, however, of the child rapidly became worse and death 
occurred on March 18, 1918 — 47 days after the injury. 

Autopsy. — Beneath the fracture of the right fronto-parietal bone was a 
purulent exudate which extended over the entire cortex of the right cerebral 
hemisphere — particularly its anterior portion. The underlying cortex was 
rather soft and upon incising it a brain abscess completely filling the entire 
right cerebral hemisphere was exposed, filled with thick, greenish, creamy 
pus (staphylococci). Left cerebral cortex negative, except at the base above 
the middle fossa where there was a small amount of purulent exudate. Line 
of fracture extended for 4 inches from the middle of the right frontal bone 
backward into the right parietal bone ; the dura had been ruptured beneath 
one portion of the line of fracture. 

Remarks. — This case-history is impressive from the standpoint of the 
great danger of an infective process, when the dura underlying the fracture 
of the skull has been torn and especially in the presence of an overlying 
laceration of the scalp ; it is most difficult and at times impossible to prevent 
an infection of the scalp laceration from occurring — even with the great- 
est care, but no scalp laceration should be tightly sutured or no drains 
inserted, and particularly is this true if there is an underlying fracture 
of the skull. 

The gradual development of the tremendous abscess of the entire right 
cerebral hemisphere, and yet with so few signs of its extent until within 



612 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

several days before the patient's death, is most instructive and merely con- 
firms the belief that there are few intracranial conditions more difficult to 
diagnose accurately than the condition of subcortical abscess — and especially 
in the comparatively silent areas of the temporo-sphenoidal and of either 
frontal lobe, and particularly the right frontal lobe ; rarely does the increased 
intracranial pressure reach a height sufficient to cause a measurable papill- 
edema of the optic disks, and it only does so when the associated meningeal 
inflammation produces a blockage of the ventricles — and then it is usually 
too late to afford a definite chance of recovery — operation or no operation. 

Case 165. — Acute severe brain injury associated with a compound de- 
pressed fracture of the vault and a penetration of the underlying dura. 
Removal of the depressed fragments of bone. Purulent meningitis. Death ; 
post-mortem examination. 

No. 332.— Charles. Eleven years. "White. School. U. S. 

Admitted July 16, 1915. Fordham Hospital. 

Operation July 16, 1915 — 2 hours after admission. Removal of depressed 
fragments of bone. 

Consultation with Doctor E. R. Cuniffe — July 25, 1915 — 10 days after 
the injury. 

Died July 26, 1915 — 10 days after injury. Purulent meningitis. 

Family history negative. 

Personal history negative. 

Present Illness. — While riding in an automobile, patient was thrown out 
of the car, which had turned over and the iron bar supporting the top pene- 
trated the right occipital area of the skull ; immediate loss of consciousness ; 
brought to the Fordham Hospital in the ambulance. The scalp surrounding 
the wound in the right occipital area w T as widely shaved, the wound itself 
cleansed with soap and water and then iodine solution, and by means of 
forceps the depressed fragments of bone were removed ; considerable hemor- 
rhage and a small amount of brain tissue welled through the dural opening ; 
two drains of rubber tissue inserted through dural opening and wet bichloride 
solution (1-5000) and dressing applied. Patient gradually recovered con- 
sciousness and made an excellent recovery; the child felt so well that the 
parents insisted upon his being removed to his home, which was permitted on 
July 23 (7 days after injury) ; the wound had apparently healed per primam 
and merely the small gauze dressing was bandaged over it. Upon arriving 
home, patient complained of a dull frontal and occipital headache, and 6 
hours later a severe general convulsion occurred and the temperature 
rapidly ascended to 104° ; he was immediately brought to the Fordham 
Hospital again and at a second operation by Doctor Cuniffe, free pus was 
found in the wound — oozing up through the dural opening ; the bony opening 
was enlarged by rongeurs, the dural opening widened and two drains of rub- 
ber tissue reinserted. The general condition, however, rapidly became worse. 

Examination (July 26, 1915 — 10 days after injury). — Consultation with 
Doctor Cuniffe. Temperature, 107.2°; pulse, 164; respiration, 52; blood- 
pressure, 106. Well-developed and nourished. Profoundly unconscious; 
weak thready pulse and shallow respiration. Wound dressed, disclosing a 
purulent secretion welling up through the dural opening (later bacteriologi- 



IN NEWBORN BABIES AND CHILDREN 613 

cal report — "pneumococci") ; rubber tissue drains reinserted and dressing 
reapplied. Marked stiffness of the neck and bilateral Kernig present. Di- 
vergent strabismus — left more than right. Pupils widely dilated and non- 
reactive to light. Reflexes — patellar absent; no ankle clonus but double 
Babinski ; abdominal reflexes absent, Fundi — retinal veins dilated, tortuous 
and buried in edematous tissue; double "choked disks" of 4 diopters of 
swelling. Lumbar puncture — straw-colored cerebrospinal fluid under high 
pressure (approximately 18 mm.) ; 15 c.c. slowly removed; later bacterio- 
logical report — ' ' pneumococci. ' ' 

Treatment. — The presence of bacteria in the form of pneumococci in the 
cerebrospinal fluid at lumbar puncture indicated an extensive diffuse puru- 
lent meningitis and as the patient was already in a moribund condition, there 
was practically nothing therapeutically which could be advised ; repeated 
lumbar punctures every 2 hours with drainage of 10-15 c.c. of the cerebro- 
spinal fluid was advocated, in addition to the routine expectant treatment — 
the condition, however, was practically hopeless and surely beyond the realm 
of surgery. The condition progressively became worse — temperature ascended 
to over 108 °, the pulse- and respiration-rates to a point where they could 
not be counted, and the patient died 18 hours later — on the tenth day 
after the injury. 

Local post-mortem examination: the condition as found at the second 
operation was confirmed in that the local area explored was saturated in the 
purulent secretion — undoubtedly an extensive purulent meningitis. 

Remarks. — The sudden and rapid onset of the symptoms and signs of a 
meningitic infection was due chiefly to the site of the infective process being* 
in the occipital area subtentorially, and therefore its extension to the medulla 
and down into the spinal canal and forward into the basal fossae of the skull 
was a most sudden and overwhelming one ; the usual preliminary symptoms 
and signs of headache, increasing stupor and convulsive seizures themselves 
were thereby absent, until the infective process had become an advanced 
and extensive one. 

In compound depressed fractures of the skull, when the underlying dura 
has been penetrated, with or without a direct damage to the underlying 
brain tissue, it is better surgical judgment to perform first, an ipsolateral 
subtemporal decompression and drainage (even in the absence of a high 
intracranial pressure), and then the local operation of removing the de- 
pressed fragments of bone and the insertion of drains ; in this manner, the 
danger of a localized meningitis is lessened, and if it should occur then the 
danger of the infected process becoming an extensive and diffuse one is 
frequently avoided, and it would seem at times even prevented. There is 
always in these patients an increased intracranial pressure due to the asso- 
ciated edema of the surrounding brain tissue, and if this pressure is lowered 
by a subtemporal decompression and at times by a suboccipital decompres- 
sion, then the tissues can resist the infective process much more successfully. 

It is unfortunate that a complete autopsy could not be obtained in 
this case ; local examinations are seldom of any real value. 

Case 166. — Acute severe brain injury associated with a compound 
depressed fracture of the vault ; removal of the depressed fragment of bone ; 



6i 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

cerebral hernia and fungus cerebri. Left subtemporal decompression and 
repair of hernial protrusion. Meningitis. Death. 

No* 244. — Josephine. Eight years. White. School. U. S. 

Admitted March 6, 1915. United Hospital, Portchester, N. Y. Referred 
by Doctor C. H. Bonnell. 

Operation March 29, 1915 — 23 days after injury. Left subtemporal 
decompression and repair of hernia cerebri. 

Died April 5, 1915 — 5 days after operation. Purulent meningitis. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street about three weeks ago, 
patient was knocked down by an automobile so that the left side of her head 
struck a large stone ; unconscious for several minutes ; carried to the United 
Hospital, where a fragment of bone of one silver dollar in size was removed 
by forceps through the scalp laceration over the anterior lower left parietal 
area of the vault; the underlying dura had been torn so that contused cere- 
bral tissue was lying in the open wound. The intracranial pressure was so 
high that the dura could not be sutured ; two drains of rubber tissue inserted 
and the scalp laceration was approximated with fine catgut. Child was 
apparently making an excellent recovery until the bulging of the scalp 
laceration became more and more pronounced, and on the 14th day after the 
injury the scalp wound was opened, allowing brain tissue to protrude and 
then the typical history of cerebral hernia and its resulting fungus followed : 
the fungoid mass became larger daily and a purulent discharge appeared, 
while the patient developed a right facial paralysis of the cortical type and 
a weakness of the right arm associated with a motor aphasia. 

First Examination (March 29, 1915 — 23 days after injury). — Consulta- 
tion with Doctor Bonnell. Temperature, 103° ; pulse, 130; respiration, 32; 
blood-pressure, 124. Semiconscious ; upon being aroused she turns over rest- 
lessly and immediately becomes stuporous again. Paralysis of right side 
of face associated with a definite weakness of the right arm and possibly 
of the right leg. Unable to talk, although an attempt is made to do so when 
aroused, but the sound is inarticulate. Over the anterior lower portion of 
the left parietal bone is an infected fungoid tumor-mass — the size of a 
lemon ; no pulsation visible. Pupils — left larger than right ; reacts to light 
sluggishly. Reflexes : patellar — right greater than left ; right ankle clonus 
(exhaustible) and right Babinski; abdominal reflexes — right absent, left 
depressed. Fundi— retinal veins full and slightly tortuous ; nasal halves of 
both optic disks blurred— left more than right. Lumbar puncture — slightly 
cloudy cerebrospinal fluid under increased pressure (approximately 18 
mm.) ; bacteriological report showed no bacteria present — merely numerous 
leucocytes. X-ray report — ' ' irregular bony opening — 4 cm. in diameter — at 
the site of the hernial protrusion. ' ' 

Treatment. — In the hope that the hernia and fungus cerebri could be 
repaired sufficiently to permit a recovery of life at least, a left subtemporal 
decompression was advised (in spite of the serious and poor condition of the 
patient) ; naturally, the danger of a meningitis was very great indeed — 



IN NEWBORN BABIES AND CHILDREN 615 

operation or no operation ; in fact, the operation would give the patient her 
only chance of recovery. 

Operations (23 days after injury) — First. Left subtemporal decompres- 
sion: usual vertical incision, bone removed, and no complications. Dura 
very tense, and upon incising it a slightly turbid straw-colored fluid spurted 
to a height of 6 inches, revealing a very "wet," edematous cortex. Much 
cerebrospinal fluid escaped, permitting the brain to recede and to pulsate 
almost normally. No signs of an early localized meningitis observed. Usual 
closure with 3 drains of rubber tissue inserted. As the fungoid mass was 
no longer under tension as the result of the ipsolateral decompression, it was 
thought advisable to attempt its repair. Second. Repair of hernia and 
fungus cerebri : an S-shaped incision of the scalp, both in front and behind 
the tumor-mass, permitted two large flaps of scalp to be used to cover the 
cranial defect which was thoroughly cleansed with iodine and then with alco- 
hol; the destroyed and purulent extruded cerebral tissue was now excised, 
allowing the flap of scalp to be sutured over the deeper portions which 
receded through the bony opening. No attempt was made to suture the dura 
since its edges were under the bony rim and they could not be approximated. 
Three drains of rubber tissue inserted and the usual closure of the scalp 
made with black silk. Duration, 65 minutes. 

Post-operative Notes. — Child in only fair condition; became drowsy, 
however, within 8 hours and the paresis of the right side of the face and of the 
right arm improved ; speech was not recovered. Three days after the opera- 
tion, the temperature ascended to 105.6°, the pulse to 138, the neck became 
rigid and a definite Kernig reflex appeared; a lumbar puncture revealed 
numerous staphylococci in the cerebrospinal fluid; the condition rapidly 
became worse and the patient died 5 days after operation and 28 days after 
injury — a death typical of a diffuse purulent meningitis. 

Remarks. — The extreme and late condition of this patient — practically a 
moribund one — hardly made the operative attempt to obtain a recovery a 
j ustifiable one, and yet it offered the patient her only opportunity for recov- 
ery. It would have been better surgical judgment to have performed merely 
the decompression, and then later if the hernial and fungoid mass had im- 
proved, then it could have been repaired ; the danger of a meningitis was very 
great in either case — and possibly a localized meningitis was already present 
at the time of the operation ; the absence, however, of bacteria in the spinal 
cerebrospinal fluid did not conclusively exclude it, except that a diffuse 
cerebrospinal meningitis was not present. 

This case-history is another illustration of the danger of complications 
in performing a local operation upon depressed fractures of the vault, espe- 
cially in the presence of an increased intracranial pressure and also in 
a compound fracture — depression ; a preliminary decompression is much the 
safer and better procedure, since it lessens the danger of a meningitis and 
also any operative damage to the underlying cerebral cortex at the site of 
the depressed bone. At times, in selected patients, an ipsolateral decom- 
pression may itself suffice together with repeated daily lumbar punctures. 

The motor aphasia and right facial paralysis of the cortical type are very 
characteristic of cortical lesions in this area in right-handed patients. 



616 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Case 167. — Acute severe brain injury associated with fractures of the 
vault and of the base and with extreme cerebral edema, but no intracranial 
hemorrhage ; signs of high intracranial pressure producing an early medul- 
lary compression and edema. No operation. Death ; autopsy. 

No. 993.— George. Five years. White. U. S. 

Admitted June 15, 1918 (1.15 p.m.) — 15 minutes after injury. Poly- 
clinic Hospital. 

Died June 17, 1918 (3 a.m.) — 38 hours after injury. Medullary -edema. 

Family history negative. 

Personal history negative. 

Present Illness. — Child fell from an open window to the pavement below, 
a distance of 20 feet, striking upon the forehead ; immediate loss of conscious- 
ness ; carried immediately to the hospital by the mother. 

Examination upon admission (15 minutes after injury). — Temperature, 
97.8° ; pulse, 104; respiration, 26 ; blood-pressure, 90. Unconscious but very 
restless; unable to arouse patient sufficiently for him to answer questions. 
Pulse very weak and irregular. In the middle of the frontal bone was a small 
punctured scalp wound extending down to the bone; careful probing re- 
vealed no depression or fracture of the underlying bone (wound swabbed 
out with iodine, rubber tissue drain inserted and sterile dressing applied). 
Profuse bleeding from nose but no cerebrospinal fluid observed. Both orbits 
swollen and ecchymotic ; mastoid areas negative. No paralysis of extremities 
ascertained. Pupils slightly enlarged but react to light normally. Reflexes 
— patellar present, left possibly greater than right; no ankle clonus nor 
Babinski ; abdominal reflexes cannot be elicited. Fundi negative. No fur- 
ther examination made at this time in order that the shock might not be 
prolonged or increased. 

Treatment. — Vigorous shock measures instituted together with the rou- 
tine expectant palliative treatment. Within 6 hours, the general condition 
of the patient improved in that the temperature ascended to 99°, the blood- 
pressure to 102, while the pulse- and respiration-rates descended to 96 and 
24, respectively ; the child became semiconscious but not sufficiently to answer 
questions ; the reflexes became more active but equal and the fundi were 
negative. It was decided to wait until the following day to perform a 
lumbar puncture. 

Examination (18 hours after admission). — Temperature, 108°; pulse, 
80; respiration, 22; blood-pressure, 108. General condition of the patient 
much better ; drowsy and stuporous and yet he answers questions and makes 
his wants known ; complains of ' ' pain in head. ' ' Both orbits ' ' swollen shut ' ' 
and are bluish ; right mastoid area ecchymosed. Otoscopic examination nega- 
tive (bleeding from nose had ceased within 4 hours after admission) . Pupils 
equal and react to light normally. Reflexes — patellar exaggerated but equal ; 
no ankle clonus or Babinski, but no plantar flexion of either foot ; abdominal 
reflexes depressed but equal. Fundi — retinal veins enlarged; lower nasal 
margins of both optic disks slightly blurred by edema. Lumbar puncture — 
clear cerebrospinal fluid under mild pressure (14 mm.) ; 10 c.c. slowly re- 
moved as a therapeutic means of drainage and this was to be repeated daily as 
an aid to the expectant palliative treatment. X-ray (Doctor G. W. Welton) 






IN NEWBORN BABIES AND CHILDREN 617 

— "multiple fractures through the posterior portion of the right frontal 
bone and the anterior portion of the parietal bone downward toward the 
base and also a horizontal fracture through the upper portion of the right 
squamous bone and anteriorly downward toward the right external angular 
process; no depression of the fragments observed" (Fig. 180). 

Treatment. — Expectant palliative treatment continued; careful and 
frequent observations of the patient as usual. The patient remained in 
practically the same condition throughout the day until 8 o'clock in the 
evening (31 hours after the injury), when the child became very restless 
and confused mentally, attempted to get out of bed three times and had to 
be restrained in addition to the use of codeine (grains y 2 , hypodermically) 
every hour for three doses; the pulse- and respiration-rates were at this 
time 88 and 26, respectively (due undoubtedly to the emotional excitement 
and the struggling, and 
therefore a confusing obser- 
vation) ; the temperature had 
risen to 101.8°; no ophthal- 
moscopic examination was ""~* 
made at this time. Three 

and a half hours later >?■ 

(11.30 p.m.), patient became 
quiet, apparently sleeping; 
the temperature was 102.4°, 
the blood-pressure 112, while | V 

the pulse- and respiration- 
rates had descended to 68 
and 16, respectively (and 
considered at this time as be- 
ing due to the codeine) ; the 
fundi, however, disclosed di- 

, , .. , . . , FlG. 180. — Multiple fractures of the entire vault in a patient 

lateQ retinal Veins With an having an extreme intracranial pressure due to cerebral edema 

T , • o n i alone — no intradural hemorrhage being present. Early medul- 

ObSCUratlOn Ot the nasal kry edema and the death of the patient. 

halves of the temporal mar- 
gins of both optic disks. No lumbar puncture was performed at this time 
as it should have been in order to estimate accurately whether the intra- 
cranial pressure was rapidly increasing or not. One hour later, the pulse 
(as taken by the nurse) was only 44 and the respiration but 6 per minute 
and very irregular — "the child would stop breathing for almost a minute 
and then begin again rapidly" (typical Cheyne-Stokes respiration) ; the 
temperature was 101.4° and the blood-pressure 112; both pupils were con- 
tracted and the reflexes were equally increased but no typical Babinski 
was elicited ; the fundi revealed dilated retinal veins and edematous obscura- 
tion of all the details of both optic disks — a papilledema, but not one of 
measurable swelling. An immediate operation was advised, but while the 
operating-room was being prepared, the pulse- and respiration-rates began 
to ascend rapidly so that at one o'clock (one-half hour later), they were 
78 and 18, respectively, 10 minutes later — 94 and 28, respectively, and 20 
minutes later — 122 and 36, respectively — that is, the sodden onset ot* an 



618 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



acute medullary edema and therefore no operation was performed, as it was 
realized that all operative procedures were too late and useless. The con- 
dition of the patient rapidly became worse in that the temperature quickly 
ascended to 106°, the pulse- and respiration-rates to 148 plus and 46 plus, 
respectively, whereas the blood-pressure dropped to 84 ; pupils became dilated 
and non-reactive to light, all reflexes were abolished, and the patient died at 
3 a.m. (2i/2 hours after the extreme signs of medullary compression of low 
pulse- and respiration-rates were observed and 38 hours after injury) — a 
death typical of acute medullary edema. 

Autopsy. — A linear fracture extended from the centre of the right 
frontal bone obliquely downward and inward along the cribriform plate of 
the ethmoid bone through the middle of the sphenoid bone, where it almost 

joined another line of fracture which 
extended horizontally through the 
upper portion of the right squamous 
bone and extending obliquely 
through the right greater wing of 
the sphenoid into the body of the 
sphenoid bonq itself; both orbital 
plates of the frontal bone were frac- 
tured and the right anterior portion 
of the entire skull was slightly mov- 
able owing to these fractures extend- 
ing into the sphenoid bone (Fig. 
181). Right temporal muscle was 
ecchymotic and contained free blood 
among its fibres, owing to the pres- 
ence of the fracture of the underlying 
bone. Xo hemorrhage intracranially 
ascertained — either extradural or 
subdural — but the brain itself, both 
above and below the tentorium, was 
very edematous and swollen from the acute cerebral edema — so much so that 
the cerebral convolutions were flattened ; the medulla itself was boggy and 
"water-logged." Ventricles negative. 

Remarks. — It was gross carelessness that this patient was not observed 
more carefully and the signs of an increasing intracranial pressure ascer- 
tained earlier by means of the ophthalmoscope and the spinal mercurial 
manometer, and thus the acute medullary compression would undoubtedly 
have been recognized and anticipated, so that its early relief by a subtem- 
poral decompression and drainage could have been advised and possibly 
the recovery of the patient obtained. The patient being a child, however, 
it was thought that he could withstand and ' ' take care of ' ' any gradually 
increasing intracranial pressure, and it was not suspected that the pressure 
intracranially was increasing so rapidly; the fact also that the sudden 
increase of the intracranial pressure occurred late at night when the patient 
was under the observation of the nurse alone (the house doctor only to be 




Pig. 181. — Linear basilar fractures of the right 
middle and both anterior fossae in a patient 
having: a high, intracranial pressure and dying 
from an acute medullary edema — there being no 
signs of an intradural hemorrhage. 



IN NEWBORN BABIES AND CHILDREN 619 

called following any marked change in the condition of the patient) — this 
fact also undoubtedly contributed to the unfortunate result of this case. 

The absence of an intracranial hemorrhage as a factor in the extreme 
increase of the intracranial pressure is remarkable only in the fact that 
these acute cerebral edemas following cranial traumata, with and without a 
fracture of the skull, occur much more frequently in adults than in children — 
their most frequent occurrence being in elderly adults having nephritic and 
arteriosclerotic conditions, and especially in alcoholic adults in whom the 
typical "wet" brain can be produced by even trivial cranial traumata. 
Children, however, are usually able to withstand the effects of cerebral edema 
following cranial trauma, and it is in only rare instances, as in this patient, 
that the cerebral edema is of such severe degree as to produce an extreme 
intracranial pressure and its resulting medullary compression, and even 
medullary edema itself; also, children can withstand the effects of a high 
intracranial pressure much better than can adults, so that even in the pres- 
ence of a high intracranial pressure, the signs of a medullary compression 
rarely appear. 

It is surprising that no intracranial hemorrhage, and especially an extra- 
dural hemorrhage, occurred following the multiple fractures of the vault 
and of the base in this patient ; no venous sinuses were torn and the right 
middle meningeal artery escaped rupture. The bleeding from the nose per- 
sisted only 4 hours following the injury and no cerebrospinal fluid was 
observed in it — and this is rather remarkable in that the lines of fracture 
extended through the ethmoid bones and into the sphenoid bones, but the 
dura was not torn — an almost impossible escape of the dura following similar 
fractures in adults. 

Case 168. — Acute cranial injury associated with a fracture of the ethmoid 
and frontal bones but with no symptoms or signs of a severe intracranial 
lesion. No operation. Meningitis. Death; autopsy. 

No. 301. — James. Five years. White. U. S. 

Admitted December 2, 1914 — 2 days after injury. Polyclinic Hospital. 
Referred by Doctor T. M. Anderson. 

Died December 5, 1914 — 3 days after admission and 5 days after injury. 
Purulent meningitis. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing in the street, child was knocked down 
by an automobile ; dazed for several minutes but no loss of consciousness ; 
was brought to the accident room of the hospital in the automobile. Profuse 
bleeding from nose but no cerebrospinal fluid was observed ; contusion of the 
forehead in the midline with some bogginess and tenderness in this area ; 
nasal bones were found to be fractured. A temporary nasal splint applied 
and the parents of child were advised to bring him back to the hospital upon 
the following day. Neurological examination was apparently negative. Two 
days after injury, mother states the child suddenly complained of severe 
headache, became drowsy and stuporous and within one hour lost conscious- 
ness ; an ambulance was summoned immediately. 

Examination upon admission (2 days after injury).— Temperature. 



LINE OF 
FRACTURE. 



620 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

102.4° ; pulse, 120; respiration, 30; blood-pressure, 112. Unconscious. Both 
orbits closed by edema and entire frontal area edematous and boggy ; clotted 
blood in both nostrils ; no mastoid ecchymoses ; otoscopic examination nega- 
tive. Respiration rather deep and stertorous and very suggestive of Cheyne- 
Stokes type in its slight irregularity. Occasional twitching of the right 
facial muscles. No paralyses of the extremities ascertained. Pupils equal 
and react normally ; eyes have a fixed stare. Reflexes — patellar exaggerated, 
right possibly greater than left ; exhaustible double ankle clonus and double 
Babinski; abdominal reflexes present and equal. Fundi — retinal veins 
enlarged ; entire retinae edematous and suffused — particularly about the nasal 
margins of both optic disks, which are obscured by the edema. Lumbar punc- 
tures — turbid cerebrospinal fluid under increased pressure (approximately 

16 nrm.) ; 14 c.c. slowly removed; bac- 
teriological report (Doctor Jeffries) — 
"numerous diplococci, most probably 
pneumococci. ' ' Leucocyte count, 
27,000; 80 per cent, polynuclears. 
X-ray (Doctor A. J. Quimby) — "lin- 
ear fracture of one and a half inches 
extending upward from the nasal 
bones into the right frontal bone just 
to the right of the midline." 

Treatment. — The routine expect- 
ant palliative treatment; several 
doses of the anti-pneumococcic serum 
were injected; 4 lumbar punctures 
with removal of 15 c.c. of turbid cere- 
brospinal fluid were performed within 
24 hours. The condition of the pa- 
tient, however, steadily became worse 
in that within 30 hours, the tempera- 
ture had become 104°, the pulse- and 
respiration-rates 138 and 36, respect- 
ively, while the double Kernig test became more marked and the rigidity of 
the neck caused the position of opisthotonos to be assumed ; the respiration 
became typical of Cheyne-Stokes irregularity; spasmodic twitchings of the 
muscles occurred all over the body but no general convulsive seizure fol- 
lowed; the patient became profoundly unconscious, the temperature finally 
ascending tc 107.8° when the patient died — 66 hours after admission and 
105 hours after the injury. 

Autopsy (the Coroner's physician refused permission for a post-mortem 
examination, but after the body had been turned over to the parents consent 
Was then obtained by us for the performance of an autopsy ) . — A fracture of 
the nasal bones had extended backward into the ethmoid bones to the right of 
the crista gallas ; the continuation of this line of fracture extended upward 
into the frontal bone just to the right of the median line for a distance of 
almost 2 inches (Fig. 182). The dura overlying the fracture at the base had 
been torn for a distance of one-half inch and it was through this channel that 







Fig. 182. — Wide linear fracture of the right 
anterior fossa in a patient developing a purulent 
meningitis; autopsy did not reveal an intradural 
hemorrhage or cerebral laceration and this patient 
would undoubtedly have recovered if the infec- 
tion had not occurred. 



IN NEWBORN BABIES AND CHILDREN 621 

the infective process had travelled. (It is surprising that no cerebrospinal 
fluid had appeared in the discharge of blood from the nose at the time of the 
injury, as it would seem from these findings that it must have been present.) 
Extensive purulent exudate and secretion over the base of the skull, par- 
ticularly in the- anterior and middle fossa? ; meningitic exudate extended 
over both frontal lobes and backward to the Sylvian fissure. No hemorrhage 
or cortical laceration ascertained. Ventricles also contained a purulent 
secretion. Infective' process had extended down into the spinal canal. 

Remarks. — Even if this patient had been kept in the hospital upon being 
brought there following the cranial injury, it is probable that the infective 
meningitis would also have occurred in this patient, even with the best 
of treatment, and yet in all doubtful cases such as this one, the hospital 
is the proper place for their treatment rather than at home ; although the 
parents denied any irrigations or "cleansing" of the nose itself, yet this 
method of treatment is so frequent among the laity that its danger and risk 
are very great indeed. This type of fracture associated with a tear of the 
overlying dura is a most serious one from the standpoint of a meningitic in- 
fection, and a most careful examination of the nasal discharge should always 
be made in order to ascertain the presence of cerebrospinal fluid or not ; if not 
present, then the risk of an infective meningitic process is slight, whereas if 
cerebrospinal fluid is definitely found in the nasal discharge, then the patient 
should be watched most carefully, the expectant palliative treatment rigor- 
ously enforced, and if there appear the earliest signs of a meningitic compli- 
cation — such as slight headache and an increased cell count of cerebrospinal 
fluid is definitely found in the nasal discharge, then the patient should 
be watched most carefully, the expectant palliative treatment rigorously 
enforced, and if there appear the earliest signs of a meningitic complica- 
tion — such as slight headache and an increased cell count of cerebrospinal 
fluid, an early subtemporal decompression and drainage should be imme- 
diately performed in order to lessen the intracranial pressure and to 
hasten the cessation of the discharge of the cerebrospinal fluid through the 
nose (the longer it persists the greater the risk of an infection). In the 
later cases' when bacteria have already appeared in the cerebrospinal fluid 
at lumbar puncture, these patients are beyond the aid of any surgical treat- 
ment, in that the meningitis has been permitted to become a diffuse one 
and the prognosis of these patients is absolutely bad — no matter what 
the treatment; the various anti-meningitic sera may be administered in 
hope, but it is most rare for one of these patients to recover — let alone 
approximate normality. 

Case 169. — Acute severe brain injury following an apparently trivial 
"bump" upon the head and causing a linear fracture of the vault : tear of 
the right middle menigeal artery with the slow formation of a huge extra- 
dural hemorrhage. No operation. Death. Autopsy. 

No. 271.— William. Seven years. White. School. U. S. 

Admitted May 12, 1914 — 2 days after injury. Polyclinic Hospital. 
Keferred by Doctor C. H. Chetwood. 

Died May 12, 1914 — 40 minutes after admission and 2 days after injury. 
Acute medullary edema. 



622 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 







Family history negative. Personal history negative. 
Present Illness. — Two days ago (46 hours), while playing in the school- 
yard at noontime, the patient struck his forehead upon the brick pavement ; 
no loss of consciousness, but merely stunned momentarily; the school-nurse 
applied a bandage, made two photographs of the patient (Figs. 183 and 184), 
and he was able to continue playing after several minutes with apparently 
only a slightly lacerated wound of the occiput and over the right frontal 
bone. No bleeding from nose, mouth or ears. The child attended school that 
afternoon, played after school and that evening complained merely of a 
slight headache ; slept well at night, attended school the f ollowing day and 
except for a slight headache he was able to do his lessons and to play as 
usual ; again complained of the headache at supper that evening and went 
to bed earlier — immediately after supper. The following morning, child 
still complained of the headache, but he attended school and during the 

morning intermission he did 
not leave his seat and was 
found there crying by the 
teacher; "my head hurts. " 
Teacher was assisting him to 
walk to a rest-room when he 
suddenly became unconscious. 
An ambulance was summoned 
and the patient was im- 
mediately brought to the hos- 
igg|i», pital; in the ambulance the 

^ patient vomited twice, but did 

not regain consciousness. No 
convulsive seizures. 

Examination upon admis- 
sion (47 hours after injury and 
30 minutes following loss of 
consciousness). — T e m p e r a- 
ture, 99.8°; pulse, 68; respira- 
tion. 14; blood-pressure, 110. 
Profound unconsciousness. 
Both eyes were widely opened with conjugate upward deviation. Both pulse- 
and respiration-rates were irregular and of the Cheyne-Stokes type. Slight 
contusion and laceration of the scalp of the right forehead and of the occiput. 
Slight right orbital and right mastoid ecchymoses. Left leg twitched spas- 
modically. Left side of body possibly more relaxed and limp than right side 
of body; both arms flexed and spastic while legs were extended and stiff 
— right more than left. Xo clotted blood in nares or in any external auditory 
canals ; ostoscopic examination negative. Pupils — right widely dilated while 
left was contracted to pin-point size. Reflexes: patellar — very much exag- 
gerated, right more than left; double Babinsky, right more than left; 
double Gordon and Oppenheim present; abdominal reflexes — left absent, 
right depressed. Fundi — retinal veins tortuous and buried in edematous 
tissue; double "choked disks" of 2 diopters of swelling and thus all the 
details of both optic disks obscured as the result of this measurable papill- 



:; ! 






Fig. 183. — Small laceration of the scalp following 
a "bump" sufficient to fracture the vault and causes 
rupture of the right middle meningeal artery. 



IN NEWBORN BABIES AND CHILDREN 



623 



edema. Lumbar puncture — clear cerebrospinal fluid under a high pressure 
(approximately 26 mm.) ; only 4 c.c. permitted to escape. 

Treatment. — An immediate right subtemporal decompression was ad- 
vised, and, while waiting for the nearest relative to come to the hospital to 
give consent for the operation, the patient was prepared by having the head 
shaved and the operating-room was ordered. Within 20 minutes, however, 
after the patient's admission to the hospital, the condition of the patient 
rapidly became worse in that the pulse- and respiration-rates began to ascend 
rapidly to 84 and 26, respectively, 
the temperature to 102. 8°, while the 
blood-pressure descended to 100; 
the left pupil now became dilated 
and the spasticity of the arms and 
legs changed to one of flaccidity 
and an incontinence of the urine 
occurred. This condition rapidly 
progressed so that 30 minutes 
after admission, the temperature 
had reached 105.6°, the pulse- 
and respiration-rates 126 and 38, 
respectively, while the blood- 
pressure had decreased to 86 ; the 
reflexes were all abolished, both 
pupils widely dilated, and the 
patient died from a typical medul- 
lary edema, 40 minutes after 
admission. 

This patient was within the 
jurisdiction of the Coroner's 
office; the Coroner's physician, 
Doctor T. D. Lehane, after view- 
ing the body in the hospital 
morgue — in fact, not even touch- 
ing the body — refused to perform an autopsy in that, ' ' the cause of death 
is very simple — a fall upon the head, hemorrhage of the brain and death ; 
there is no question as to the cause of death and an autopsy, therefore, is 
not warranted. ' ' In spite of our urgent request and even pleadings to be per- 
mitted to ascertain accurately the cause of death and that it might not be 
so simple as described or supposed and that the clinical history was a most 
interesting, instructive and even baffling one, yet this omniscient seer could 
see no reason for permitting an autopsy of the skull to be performed. It 
is very interesting and an excellent commentary upon such an attitude of a 
physician of the Coroner's office in that both the father and the mother of 
the child were not at all satisfied as to the cause of death and. after the 
Coroner had gone, permission was obtained from them to perform a post- 
mortem examination of the intracranial contents. 

Autopsy. — Linear fracture of 2 inches extended from the posterior por- 
tion of right frontal bone obliquely backward into the upper portion o\' the 
right squamous bone, where it ended (Fig. 185) ; in its course, it traversed 




Fig. 184. — Right mastoid ecchymosis in a patient 
having a supposed trivial "bump" over the right eye- 
brow. Death occurred two days later from a large 
extradural hemorrhage. 



624 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



LINE. OF 

FRACTURE 



the bone channeled by the right middle meningeal artery and had thus torn 
it — not all the way through but only a tear of one-third of its wall. A 
large extradural hemorrhage — the size of a small grape-fruit — compressed 
the entire right cerebral hemisphere toward the midline and almost one inch 
beyond the midline and the falx-cerebri was deviated that distance to the 
left ; the right ventricle was completely collapsed and its walls compressed 
together. Intradurally, there was no hemorrhage or other lesion except the 
extreme compression due to the right extradural hemorrhagic clot. Sub- 
tentorially about the cerebellum and the medulla was much cerebrospinal 
fluid. No fracture of the base ascertained. 

Remarks. — This case-history is an unusual one and yet similar cases 
occur not so infrequently but that each patient having a cranial injury and 
followed by persistent headache should be examined at least ophthalmo- 
scopically for fear that a similar intracranial lesion may have occurred. 

In adults, it is most 
unusual for a similar 
lesion to occur and yet 
not produce the symp- 
toms and signs of its 
presence much more 
rapidly and with 
much greater inten- 
sity than in children, 
in whom, as is well 
illustrated in this 
patient, an intracran- 
ial lesion of extreme 
degree may occur 
within a period of 
days and yet there be 
few symptoms and 
signs of its presence. Careful neurological examinations, and especially the 
use of the ophthalmoscope and the lumbar puncture needle, are most valu- 
able in their early recognition. 

It is rare for an extradural hemorrhage to occur alone in patients having 
cranial injuries — much more infrequent than the text-books would lead us 
to believe, and usually these extradural lesions are associated with definite 
intradural complications of hemorrhages and cerebral edema. The early 
dilatation of the right pupil and the contraction of the left pupil indicated 
the paralytic effect upon the homolateral pupil of the compression of the 
right cerebral hemisphere, while the irritative effect upon the left cerebral 
hemisphere was revealed in the contracted left pupil; as the intracranial 
pressure became even higher, then the left pupil, too, became dilated as the 
patient entered into the stage of medullary edema. The absence of convulsive 
seizures confirmed the belief that the lesion was an extradural rather than 
a subdural one. 

It is possible that the hemorrhage from the right middle meningeal 
artery could have been lessened and even prevented to a marked degree, if 




Fig. 185. — Linear fracture of the right vault and of no impor- 
tance if it had not ruptured the right middle meningeal artery, 
thereby causing a large extradural hemorrhage to occur slowly and 
the subsequent death of the patient. 



IN NEWBORN BABIES AND CHILDREN 625 

this child could have been put in bed, an ice-helmet applied, absolute rest 
and quiet enforced, liquid diet and a daily movement of the bowels assured ; 
codeine, if necessary. In this manner, the blood-pressure could have been 
definitely lowered and the hemorrhage possibly controlled until the bleeding 
vessel would have thrombosed at the site of its tear. An excellent recovery 
could have undoubtedly been obtained in this patient in any event, if the 
condition had been recognized earlier and before the medullary compression 
had become extreme and the pulse- and respiration-rates reached their 
lowest levels ; if a right subtemporal decompression had then been performed, 
it would thus have made possible the evacuation of the extradural hemor- 
rhage and the ligation of the right middle meningeal artery below its point 
of rupture ; after the signs of medullary edema had once appeared in the 
rapidly rising pulse- and respiration-rates, the ascending temperature and 
the descending blood-pressure, it was useless to advise any operative pro- 
cedure as these patients all die — operation or no operation. 

Case 170 — Acute severe brain injury associated with fractures of the 
vault and of the base and with a subdural hemorrhage ; a mild increase of the 
intracranial pressure. No operation. Purulent meningitis. Death ; autopsy. 

No. 274. — Emma. Six years. White. School. U. S. 

Admitted May 16, 1914. Polyclinic Hospital. 

Died May 28, 1914 — 12 days after injury. Purulent meningitis. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing tag in the street, the patient was knocked 
down by an automobile ; immediate loss of consciousness ; brought to the 
hospital in the automobile. 

Examination upon admission (15 minutes after injury). — Temperature, 
97.6° ; pulse, 146 plus ; respiration, 36 plus ; blood-pressure, 90. Unconscious 
and in extreme shock ; pulse scarcely palpable and very thready. Contusion 
of entire scalp and a boggy hematoma over the right parieto-squamous area — 
giving the sensation upon palpation of an underlying fracture of the skull. 
Profuse bleeding from nose and both ears ; a large quantity of cerebrospinal 
fluid mixed in the blood. Left side of body apparently paralyzed — more lax 
and limp than the right side. Pupils dilated and do not react to light. Re- 
flexes — patellar cannot be elicited ; no ankle clonus but an inconstant left 
Babinski ; abdominal reflexes absent. Fundi negative. No further examina- 
tion of the patient was made at this time for fear of increasing the shock. 

Treatment. — Vigorous shock measures— especially heated blankets and 
hot coffee per rectum, 3 ounces every 2 hours. In spite of the treatment, 
patient remained in this extreme condition of shock for over 12 hours, and it 
was only after 24 hours that it could be said that the condition was slightly 
better ; the expectant palliative method was continued and the child gradually 
recovered from the extreme condition of shock, so that 48 hours after the 
injury, the temperature had ascended to 99° and the blood-pressure to 104. 
while the pulse- and respiration-rates had descended to 126 and 30, respec- 
tively; a large amount of blood and cerebrospinal fluid continued to dis- 
charge from both ears ; an ophthalmoscopic examination was practically nega- 
tive, while a lumbar puncture revealed blood-tinged cerebrospinal fluid and 
40 



626 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






under mild pressure only ( approximately 11 mm. ) . The apparent weakness 
of the left side of the body had disappeared. 

The patient continued to improve for 6 days in that the general con- 
dition became more normal and there were no marked signs of an increasing 
intracranial pressure due undoubtedly to the discharge of straw-colored 
cerebrospinal fluid from both ears and thus preventing a definite increase of 
the intracranial pressure ; the pulse- and respiration-rates, however, re- 
mained above 120 and 28, respectively, and the blood-pressure did not rise 
above 106; the child remained in a semiconscious condition. Eight days 
after admission, the temperature suddenly became 105.4°, when the follow- 
ing examination was made : 

Examination (8 days after admission). — Temperature, 105.4°; pulse, 

142 ; respiration, 34 ; blood- 
pressure, 106. Very difficult 
to arouse and not sufficiently 
to answer questions. Sug- 
gestive rigidity of the neck 
and a possible double Ker- 
nig sign. Discharge from 
both ears has ceased ( 3 days 
before) ; an otoscopic exam- 
ination reveals a laceration 
of the lower halves of both 
tympanic membranes, and in 
the right middle ear a small 
amount of purulent exudate 
was found. Pupils slightly 
enlarged and equal. Re- 
flexes — patellar active, left 
possibly more than right; 
exhaustible left ankle clonus 
and suggestive left Babin- 
ski; abdominal reflexes diffi- 
cult to elicit. Fundi — 
retinal veins enlarged ; nasal margins of both optic disks blurred by edema. 
Lumbar puncture — cloudy cerebrospinal fluid under slightly increased pres- 
sure (approximately 11 mm.) ; bacteriological report — "numerous chains of 
streptococci observed." X-ray report (Doctor A. J. Quimby) — "curvilin- 
ear fracture of right squamous bone extending downward toward right 
external auditory meatus" (Fig. 186). 

Treatment. — The presence of streptococci in the cerebrospinal fluid at 
lumbar puncture indicated that the meningitis was already a diffuse one 
and therefore the condition was practically a hopeless one and too far 
advanced to be benefited in any real way by an operative procedure of drain- 
age. The condition of the patient rapidly became worse — the temperature 
ascending as high as 108.2°, so that the patient finally died on the twelfth 
day after injury and the fourth day following the sudden rise of temperature. 
Autopsy.— & fracture of skull extended vertically downward through 




Fig. 186.- — -Very faint linear fracture of the right squamous 
bone in a patient dying from a purulent meningitis — the infec- 
tion having entered through the line of fracture in the right 
middle ear. 



IN NEWBORN BABIES AND CHILDREN 



627 



the right squamous bone into the right petrous bone and transversely across 
it through the sella turcica and into the left petrous bone and along its pos- 
terior crest to the left middle ear (Fig. 187). Both middle ears were filled 
with a purulent exudate. The middle fossa of the skull was filled with a 
cloudy purulent exudate which has extended over the surface of both hemi- 
spheres. Small hemorrhagic clots lay beneath both frontal lobes, which were 
slightly contused. No cortical lacerations found. Small amount of purulent 
exudate subtentorially. Ventricles negative. 

Remarks. — It would seem that in this patient, the infective process had 
extended intracranially through the ruptured tympanic membranes ; fortu- 
nately no local treatment of the ears had been attempted — such as irrigation, 
swabbing out with cotton and other such meddlesome procedures which 
would facilitate the extension of an infective process intracranially. In this 
patient, it is very probable that the continued discharge of cerebrospinal fluid 
and blood from both ears for a period 
of 5 days made it more possible for an 
infective process to occur in the middle 
ears and therefore, although this dis- 
charge of blood and cerebrospinal 
fluid lessened and prevented a marked 
increase of the intracranial pressure, 
yet it did so at the greater risk of an 
infection and resulting meningitis ; for 
this reason, the prolonged drainage of 
blood and cerebrospinal fluid through 
the ears as a means of lowering and 
preventing an increased intracranial 
pressure is a rather dangerous means 
of drainage, and it is better surgical 
judgment in these patients, in whom 
the discharge of blood and cerebrospinal 
fluid continues longer than 2 days and 
in whom there are signs of an increased intracranial pressure, that a sub- 
temporal decompression and drainage through a clean area of the scalp 
is not only a more efficient means of drainage but a much safer one — the 
risk of the operation being slight compared with the great danger of 
infection following a prolonged drainage through the ears or nose. 

It is always surprising in these patients to have the onset of a purulent 
meningitis appear so suddenly and ushered in by either a rapid increase 
of the temperature or a convulsive seizure ; at times, increasing stupor and 
headache are very frequent signs and should indicate the necessity of an 
immediate examination and particularly a lumbar puncture. 

The presence of bacteria in the cerebrospinal fluid at lumbar puncture in 
these patients means that the infective process is a diffuse one and beyond 
operative treatment ; it is only in those cases of localized meningitis whore 
the cerebrospinal fluid at lumbar puncture is free of bacteria — in these 
patients an immediate decompression and drainage and if necessary a bilat- 
eral decompression and drainage is indicated and frequently a recovery of 




Pig. 187. — Extensive basilar fracture through 
both petrous bones and across the sella turcica, 
in a patient developing a purulent meningitis; 
death twelve days after injury. 



628 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

life is obtained. The cerebrospinal fluid may be cloudy due to an increased 
cell count resulting from the meningeal irritation, and yet no bacteria are 
present ; in these patients also an early operative procedure of decompression 
and drainage occasionally makes a recovery of life possible. 

Case 171. — Acute severe brain injury associated with a fracture of the 
vault and of the base and with subdural hemorrhage ; a gradual increase of 
the intracranial pressure. Right subtemporal decompression and drainage. 
Acute purulent meningitis. Death ; autopsy. 
No. 305. — Henry. Nine years. White. U. S. 

Admitted August 1, 1915. Polyclinic Hospital. Referred by Doctor 
John A. Wyeth. 

Operation August 9, 1915 — 8 days after injury. Right subtemporal 
decompression and drainage. 

Died August 19, 1915 — 18 days after injury. Purulent meningitis. 
Family history negative. 
Personal history negative. 

Present Illness. — While playing in the street, child was knocked down by 
an automobile ; immediate loss of consciousness ; brought to the hospital in 
the automobile. 

Examination upon admission (20 minutes after injury). — Temperature, 
97.2°; pulse, 120; respiration, 30; blood-pressure, 98. Profoundly uncon- 
scious and in severe shock. Multiple contusions of the head — especially over 
the left side, and over the entire body. Profuse bleeding from the nose and 
both ears, with much cerebrospinal fluid in the blood ; extensive ecchymoses 
of both orbits and both mastoid areas. No conjunctival hemorrhage. Pupils 
dilated and react to light sluggishly. Reflexes : patellar — obtained with diffi- 
culty, but apparently equal; no ankle clonus nor Babinski; abdominal 
reflexes absent. Fundi negative. No further examination made at this time 
on account of the severity of the shock. 

Treatment. — Vigorous shock measures instituted — rectal enemata of 
hot black coffee, external warmth and absolute rest and quiet. After six 
hours, patient gradually reacted so that the general condition improved, 
and at the end of 48 hours the temperature was 99°, the pulse- and respira- 
tion-rates were 86 and 26, respectively, while the blood-pressure had risen 
to 110 ; the aural discharge had ceased and an otoscopic examination revealed 
a laceration of the posterior halves of both tympanic membranes ; child be- 
came semiconscious and it appeared that an uneventful recovery would occur 
with the expectant palliative treatment alone. The patient, however, did 
not progress as rapidly as usual and on the sixth day, the ophthalmoscope 
disclosed the retinal veins enlarged and a definite blurring of the nasal and 
temporal margins of both optic disks, while a lumbar puncture revealed a 
blood-tinged cerebrospinal fluid under a markedly increased pressure (ap- 
proximately 16 mm.). The condition of the patient gradually became 
worse in that he became more stuporous and drowsy ; the following examina- 
tion was now made : 

Examination (8 days after admission). — Temperature, 101°; pulse, 80; 
respiration, 22 ■ blood-pressure, 114. Semiconscious and can only be aroused 
with difficulty. Right orbit still closed by edema and the ecchymosis of 






IN NEWBORN BABIES AND CHILDREN 



629 



both orbits and both mastoid areas still persists. Some tenderness over the 
left posterior parietal area. No Kernig or rigidity of the neck. Pupils 
equal and react to light normally. Reflexes — patellar very active but equal ; 
no ankle clonus but suggestive double Babinski $ abdominal reflexes equally 
depressed. Fundi — retinal veins dilated; nasal halves of both optic disks 
obscured by edema. Lumbar puncture — straw-colored cerebrospinal fluid 
under high pressure (approximately 22 mm.). X-ray report (Doctor A. J. 
Quimby) — "an irregular linear fracture of lower posterior portion of the 
left parietal bone, descending into the lambdoidal suture, which is widened ' ' 
(Fig. 188). 

Treatment. — An immediate right subtemporal decompression and drain- 
age advised to lower the increasing intracranial pressure and thus lessen the 
danger of a later medul- 
lary compression. 

Operation (8 days after 
admission). — Right subtem- 
poral decompression (only 
primary anesthesia re- 
quired) : usual vertical inci- 
sion, bone removed, and no 
complications; as there was 
found free blood in the tem- 
poral muscle beneath the 
temporal fascia, a fracture 
of the underlying bone was 
to be expected and a small 
linear fissure was found only 
2 cm. in length; there was 
a slight depression of the 
lower fragment but not suffi- 
cient for the rongeurs to be 
inserted and therefore the 
routine use of the Doyen 
perforator and burr was 

made. No extradural hemorrhage ascertained. Dura was tense, bulging 
and slightly bluish; upon incising it, bloody cerebrospinal fluid spurted to 
a height of 5 inches and upon enlarging the dural opening much bloody 
cerebrospinal fluid escaped, revealing a very swollen edematous brain, which 
began to pulsate after much free blood and cerebrospinal fluid had welled 
out of the dural opening; no cortical lacerations nor punctate hemorrhages 
observed. Usual closure with 2 drains of rubber tissue inserted. Dura- 
tion, 40 minutes, 

Post-operative Notes. — The operative recovery was uneventful and appar- 
ently the child was on the road to an excellent result ; the operative incision 
healed per primam, the child became conscious, answered questions and the 
signs of the high intracranial pressure lessened. While sitting up in bed upon 
the eighth day post-operative, the patient complained of a severe headache 
and 4 hours later a general convulsive seizure occurred ; the temperature now 




Fig. 188. — Extensive linear fracture of posterior portion of 
left vault, in a patient dying from a purulent meningitis, most 
probably resulting from an infective process extending through 
the lines of fracture involving the base of the skull. 



630 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

ascended to 104°-, the pulse- and respiration-rates to 118 and 28, respectively, 
and a profound stupor appeared; a suggestive stiffness of the neck was 
elicited and also a slight positive Kernig reaction. Lumbar puncture, how- 
ever, revealed clear cerebrospinal fluid under only an increased pressure 
of approximately 14 mm. and the cell count was 6 per c.mm. The general 
condition of the child, however, rapidly became worse, in that the tempera- 
ture ascended to 107.6°, and the pulse- and respiration-rates to 140 plus and 
38 plus, respectively; the patient became moribund and died on the eigh- 
teenth day after the injury, the tenth day after operation and the thirty- 
second hour after the onset of the headache. 

Autopsy. — Multiple lines of fracture extended into both orbital plates and 
ethmoid bones ; a line of fracture extended from the site of operation down- 
ward into right petrous bone and inward toward the sella turcica, then turned 
backward across the basilar process, one-half inch behind the posterior 

clinoid processes, and then forward 
into the apex of the left petrous bone 
and along its crest to the left exter- 
nal auditory meatus, and then 
backward into the left half of the 
lambdoidal suture which was sepa- 
rated (Fig. 189) ; the right middle 
ear contained a small amount of 
clotted blood, while the left middle 
ear contained a small amount of 
purulent exudate (the possible cause 
for the left earache of which the 
patient complained to the nurse dur- 
ing his post-operative convalescence 
and of which we were not aware). 
The operative site and the contiguous 
cerebral cortex were of normal 
appearance and no infective process 
was present, but over the entire left cerebral cortex, and especially the 
basilar portions of the inferior surfaces of both frontal lobes and sub- 
tentorially, was an extensive purulent exudate — thick, creamy pus. No 
cortical lacerations or hemorrhages observed. Both ventricles were enlarged 
from the blockage of their foramina of exit subtentorially. 

Remarks. — The absence of the purulent meningitis in that portion of the 
brain and meninges contiguous with the decompression would indicate that 
the operation itself was not the source of the infection, and the presence 
of the extensive meningitis in the neighborhood of the lines of fracture 
extending into the nose and also in the vicinity of the left ear would point 
to these fractured lines as being the channels of the infection ; the presence 
of a purulent exudate in the left middle ear might have been a secondary one 
rather than the source of the general meningitis, as there had been no puru- 
lent discharge from the left ear — merely pain which had not been consid- 
ered of sufficient importance to notify the house-surgeon. Whether the 
operation of decompression, by lessening the pressure of the adjacent cere- 







Fig. 189. — Multiple fractures of the base in a 
patient dying from a purulent meningitis, which 
resulted from an infective process that had en- 
tered intracranially through these channels. 



IN NEWBORN BABIES AND CHILDREN 631 

bral cortex, had permitted these cells to resist successfully the infective 
process cannot be stated with any certainty, and yet it is a well-known 
physiological fact that the cells of all body tissues are more resistant to 
infection when not compressed or under pressure, than they are when under 
increased pressure. The clear cerebrospinal fluid and the normal cell count, 
as obtained within 30 hours before the death of this patient, merely indicates 
that the infective process had not become a diffuse cerebrospinal one and that 
there was undoubtedly a blockage of the cerebrospinal fluid in the neigh- 
borhood of the foramen magnum. 

It was rather remarkable to ascertain that the intracranial pressure was 
increasing 8 days after the injury and yet no extensive intracranial hemor- 
rhage was present — merely a "wet," edematous condition of the brpin, and 
therefore an excellent illustration of a delayed cerebral edema of sufficient 
height to necessitate its operative lowering ; the cerebrospinal fluid was only 
slightly bloody and blood-tinged, and the prognosis was most favorable, 
especially in the absence of numerous punctate hemorrhages throughout 
the cortex. Another interesting observation was the absence of subcon- 
junctival hemorrhages, especially in the presence of such extensive frac- 
tures of both orbital plates and a small amount of hemorrhage within the 
tissues of both orbits. Also the lines of fracture in passing through both pet- 
rous bones instead of passing 1 through the sella turcica, as these fractures 
usually do, they extended posteriorly and then across the basilar process so 
that at this point the anterior portion of the base of the skull conld be 
rocked upon its posterior portion. 

Case 172. — Acute severe brain injury associated with a linear fracture 
of the vault and with an increased intracranial pressure. Purulent menin- 
gitis resulting from an infected hematoma. Subtemporal decompression 
and drainage. Death ; autopsy. 

No. 286. — Josephine. Five and a half months. White. U. S. 

Admitted September 10, 1914 — 3 days after cranial injury. Polyclinic 
Hospital. Referred by Doctor John A. Bodine. 

Operation September 10, 1914 — 2 hours after admission. Left subtem- 
poral decompression and drainage. 

Died September 12, 1914 — 44 hours after operation. Purulent 
meningitis. 

Family history negative. 

Personal history negative; fourth child, normal full-term labor and 
was considered a normal baby. 

Present Illness. — Three days ago while asleep in bed, child was struck 
over the left side of the head by an older brother with a milk bottle ; appar- 
ently no loss of consciousness and the child cried, according' to the mother, 
during the entire day ; a swelling appeared over the posterior portion of the 
left parietal area where the overlying scalp was slightly bruised ; the child 
was not considered as being- seriously hurt and no more attention was paid to 
the injury. Thirty-six hours later, however, child became ' ' feverish ' ' and 
rather drowsy and 6 hours later, definite twitchings of the right side oi 
the body occurred, but no general convulsion. Eight hours later (50 hours 
after the injury), child became stuporous, no longer noticed anything and 



632 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the temperature, now taken for the first time, was 104.2 ° ; it was noticed 
at this time that the child's neck was stiff. Upon the following day (68 
hours after the injury), it was finally thought advisable by the parents to 
bring the child to the hospital. 

Examination upon admission (3 days — 70 hours — after injury). — Tem- 
perature, 105.6 c ; pulse, 138 ; respiration, 36. Well-developed and nourished. 
Profoundly unconscious: both eyes open and staring vacantly. Position 
of opisthotonos — the neck and back being very rigid and arched ; bilateral 
positive Kernig — more marked on the left than on the right. Boggy hema- 
toma over posterior portion of the left parietal bone extending over the left 
half of the occipital bone. Xo orbital or mastoid ecchymoses. Xo clotted 
blood in nose or ears; otoscopic examination negative. Pupils enlarged 
equally and react to light sluggishly. Reflexes — patellar active, right more 
than left ; no ankle clonus but double Babinski ; abdominal reflexes absent. 
Fundi — retinal veins dilated and tortuous; all details of both optic disks 
blurred — a papilledema of 1 diopter of swelling. Lumbar puncture — 
slightly cloudy cerebrospinal fluid under increased pressure (approximately 
15 mm.) ; 10 c.c. carefully removed; bacteriological report (Doctor Jef- 
fries) — "cell count was 10 cells per c.mm. but no bacteria observed." 

Treatment. — In the hope that the meningitic irritation and inflammation 
was not a diffuse one and if a purulent meningitis was present that it was 
still a localized one. an immediate left subtemporal decompression and 
drainage was advised in the belief that it offered the patient a definite 
chance of recovery. (If bacteria had been found in the cerebrospinal fluid 
at lumbar puncture, then no cranial operation would have been attempted 
as it would have been recognized that the purulent meningitis was already 
a diffuse one and beyond the aid of surgery.) 

Operation (2 hours after admission and 72 hours after injury). — Left 
subtemporal decompression and drainage : usual vertical incision, bone 
removed, and no complications; a transverse line of fracture extended 
through the upper portion of the left squamous bone and backward below the 
site of the hematoma ; upon inserting forceps along the line of fracture into 
the hematoma over the posterior portion of the left parietal bone, a purulent 
exudate welled out (later bacteriological report — "streptococci"). Xo ex- 
tradural hemorrhage found. Dura very tense and upon incising it. much 
straw-colored turbid cerebrospinal fluid escaped and the underlying cerebral 
cortex was under such high pressure that it bulged and even ruptured before 
the loss of cerebrospinal fluid and purulent exudate was able to lower mark- 
edly the high intradural pressure. No gross hemorrhage or cortical lacera- 
tion observed. At the end of the operation, the cortex protruded but 
pulsated slightly and feebly. Usual closure with 2 drains of rubber tissue 
inserted. Duration. 25 minutes. 

Post-operative Notes. — The condition of the child did not improve and 
18 hours after the operation, the temperature suddenly ascended to 107.2 °, 
the pulse and respiration could not be counted, and this moribund condition 
persisted until the child died. 41 hours after operation. 

Autopsy. — Tissues of the scalp of the posterior portion of the vault were 
very edematous and boggy ; much purulent secretion throughout. A line of 



IN NEWBORN BABIES AND CHILDREN 



633 



fracture extended from the upper portion of the left half of the occipital 
bone transversely forward through the lower portion of the left parietal 
bone and slightly obliquely downward through the upper portion of the left 
squamous bone forward to the left frontal eminence (Fig. 190) ; another 
line of fracture extended downward from this fracture through the anterior 
portion of the left squamous bone and almost to the middle fossa; no frac- 
ture of the base ascertained. The dura underlying the line of fracture 
beneath the left parietal bone had been torn for a distance of one inch and 
it was through this channel that the infective process of the overlying 
hematoma had extended intradurally. Over the entire left cerebral cortex 
was a purulent exudate and a large collection of pus was found in both 
the middle fossa and the posterior fossa subtentorially ; the cortex of the 
right hemisphere was less affected, but along the vessels in the sulci the 
purulent exudate was collected. Ventricles also contained a purulent exu- 
date (bacteriological report — "streptococci"). At the foramen magnum, the 
medulla had been forced down into 
it and together with the purulent 
exudate, the spinal canal was appar- 
ently blocked ( and this would account 
possibly for the absence of bacteria 
in the cerebrospinal fluid at lumbar 
puncture, iy 2 hours before). 

Remarks. — It is most unfortunate 
that the seriousness of the condition 
of this child could not have been 
earlier recognized, so that a mere scalp 
incision and drainage of the infected 
hematoma might have successfully 
prevented the infective process from 
extending intracranially and if a 
localized meningitis had already 

occurred then the local operation, together with a left subtemporal decom- 
pression, would have afforded the child a definite recovery of life. 

From the findings at autopsy, it would appear that at the time of the 
operation, the meningitis was already a diffuse one with the exception that 
the spinal canal had not been invaded by the bacteria and due possibly to 
their blockage at the foramen magnum as disclosed, and therefore the opera- 
tion itself was too late to afford the child a real chance of recovery: the 
absence of bacteria in the cerebrospinal fluid at lumbar puncture made us 
feel at the time that the operation was advisable — at least, it should be 
attempted as a definite therapeutic means; if bacteria, however, had been 
present in the cerebrospinal fluid at lumbar puncture, naturally no cranial 
operation would have been advisable. 

If a meningitis had not occurred in this patient, it is very probable that 
an excellent recovery of life would have been obtained at home and a good 
prognosis possible; this case-history merely impresses us again with the 
great danger of contused and bruised tissues of the scalp and especially 




UINES OF FRAtTU; 



Fig. 190. — Tremendous linear fracture of left 
vault in a patient dying from a purulent menin- 
gitis, due to the extension of infection of an 
overlying hematoma. 



634 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

associated with an underlying hematoma in the presence of an adjacent 
fracture of the skull, whether the underlying dura is torn or not — much more 
so, if the dura is torn. All such hematomata of the scalp having the over- 
lying scalp contused and the X-ray discloses an underlying fracture of the 
skull — in all of these patients it is much better surgical judgment to incise or 
aspirate the hema toma through a clean aseptic area of the scalp and thereby 
lessen the great danger of an infective process occurring in the hematoma 
and its extension intradurally. 

Case 173. — Acute severe brain injury associated with multiple fractures 
of the vault and of the base and with extradural and subdural hemorrhages 
and cerebral edema ; high intracranial pressure causing the signs of medul- 
lary compression and then an early medullary edema. Right subtemporal 
decompression and drainage. Later infection of hematoma of scalp produc- 
ing a purulent meningitis. Death ; autopsy. 

No. 259.— Muriel. Eight years. White. School. U. S. 

Admitted April 6, 1914. Polyclinic Hospital. Referred by Doctor 
W. S. Bainbridge. 

Operation April 6, 1914 — 2 hours after admission. Right subtemporal 
decompression and drainage. 

Died April 18, 1914 — 12 days after injury. Purulent meningitis. 

Family history negative. 

Personal history negative. 

Present Illness. — While playing upon a fire-escape, child fell a distance 
of 20 feet, striking the concrete floor upon her head; immediate loss of 
consciousness ; brought to the hospital in the ambulance. 

Examination upon admission (50 minutes after injury). — Temperature, 
99°; pulse, 60; respiration, 16; blood-pressure, 116. Profoundly uncon- 
scious ; pulse regular and full and the respirations deep and slightly irregular 
— suggesting the Cheyne-Stokes type. Extensive hematomata over right 
frontal and right temporo-parietal areas and over the median portion of 
the occipital prominence. Profuse bleeding from nose but not from mouth 
or ears ; extensive orbital and right mastoid ecchymoses ; right subconjunc- 
tival hemorrhage. Otoscopic examination negative. Entire left side of body 
more limp and relaxed than the right side — undoubtedly paralyzed. Pupils 
— right dilated, left moderately contracted (one-half hour later, both widely 
dilated) ; little or no reaction to light. Reflexes — patellar exaggerated, 
left greater than right ; no ankle clonus but left Babinski ; abdominal re- 
flexes absent. Fundi — retinal veins dilated ; nasal halves of both optic disks 
obscured by edema, Lumbar puncture — bloody cerebrospinal fluid under 
high pressure (approximately 22 mm.). 

Treatment. — The signs of an acute medullary compression being present 
and it being feared that the condition of medullary edema might occur, the 
immediate operation of right subtemporal decompression and drainage was 
advised ; the nearest relatives were summoned, and while waiting one hour 
for their arrival and the consent for the operation, the condition of the 
patient rapidly changed in that an incipient medullary edema appeared; 
within one-half hour, the pulse-rate became 70, the respiration-rate 20, white 
the blood-pressure descended to 112 ; both pupils now became dilated and 



IN NEWBORN BABIES AND CHILDREN 635 

non-reaetive to light; one-half hour later, the pulse- and respiration-rates 
were 80 and 24, respectively, and the blood-pressure 108 \ one-half hour later 
(11/2 hours after admission), the pulse- and respiration-rates were 100 and 
■28, respectively, and the blood-pressure 106 ; one-half hour later, at the time 
of the operation (2 hours after admission), the pulse- and respiration-rates 
were 106 and 30, respectively, while the blood-pressure had descended to 
104 ; the neurological examination, however, remained practically the same 
as upon admission, though the pulse had become rather weak and the respira- 
tion shallow and irregular. 

Operation (2 hours after admission). — Right subtemporal decompression 
and drainage : usual vertical incision ; much free blood in the tissues of the 
scalp superficial to the temporal muscle and also in the temporal muscle itself 
beneath the temporal fascia ; a fracture of the underlying bone was there- 
fore expected and three transverse fractures were found extending ante- 
riorly across the lower portion of the right parietal bone and the upper 
portion of the right squamous bone ; the intervening bone fragment was loose 
and upon removing it, an extensive extradural hemorrhage was exposed and 
evacuated. Dura tense, bulging and slightly bluish ; upon incising it, bloody 
cerebrospinal fluid spurted to a height of 2 inches, and upon enlarging dural 
opening much free blood and cerebrospinal fluid escaped but no hemorrhagic 
clot. The underlying wet edematous cortex tended to protrude but did 
not rupture owing to the rapid escape of much blood and cerebrospinal 
fluid. No cortical hemorrhage or laceration observed. Cortex pulsated 
slightly at end of operation. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 40 minutes. 

Post-operative Notes. — At the end of the operation, the temperature was 
102°, pulse 132, respiration 30, and the blood-pressure 104; the general 
condition was apparently not worse than before the operation. Within 24 
hours after operation during which time there had been a profuse bloody 
discharge from the operative wound, the temperature descended to 102°, 
the pulse to 108, and the respiration to 24, while the blood-pressure had risen 
to 112 ; the child became semiconscious but could be aroused, although unable 
to speak: clearly ; recognized mother and understands what she says to her ; 
at the dressing of the wound upon the second day after operation, it was 
found that the bloody discharge had ceased and although the operative 
area bulged tensely, yet feeble pulsation was both visible and palpable ; 
the temperature was now only 100.8°, the pulse- and respiration-rates 100 
and 24, respectively, while the blood-pressure had increased to 116 ; the 
definite weakness of the left side of the body had lessened, although the left 
reflexes remained increased and the left Babinski persisted ; the ophthalmo- 
scopic examination of the fundi disclosed merely an enlargement of the 
retinal veins and an edematous blurring of the nasal margins of both optic 
disks. This marked improvement continued until April 11 (5 days after 
the operation) ; all sutures had been removed and although the operative 
area bulged slightly, yet it pulsated normally: at 6 a.m. the temperature 
was 100°, pulse 94, respiration 24 and the blood-pressure 114; twelve hours 
later (6 p.m.), the patient had developed a severe headache, definite stiffness 
of the neck and a double positive Kernig test, while the temperature had 



636 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

suddenly ascended to 105.6°, the pulse- and respiration-rates to 150 and 
28, respectively, and the blood-pressure to 118 ; ophthalmoscopic examination 
now disclosed dilated retinal veins with a congestion and edematous suffu- 
sion of both retinae ; lumbar puncture permitted turbid cerebrospinal fluid to 
escape under increased pressure (approximately 14 mm.) ; bacteriological 
report (Doctor Jeffries) — ''many streptococci of the short-chained type." 

Treatment. — Four injections of anti-streptococcic serum administered 
during the next 4 days ; repeated lumbar punctures with drainage of 20 c.c. 
of turbid cerebrospinal fluid were performed — and yet the condition of the 
patient gradually became worse, so that she died on the twelfth day after 
the injury — a death typical of purulent meningitis. 

Autopsy. — Hematoma over the median portion of the occipital bone was 
infected — containing much purulent secretion (bacteriological report showed 
pure streptococci) ; underlying this infection of the scalp was a transverse 
fracture of the skull, which had extended from the left squamous bone about 







LINE. OF FRACTURE. 




Figs. 191 and 192. — Tremendous horizontal linear fracture of the entire posterior vault of the skull in 
a patient developing a purulent meningitis from an infected hermatoma overlying the line of fracture; 
death occurred on the twelfth day following the injury. 

2 cm. above the external auditory meatus backward across the occipital bone 
and then forward into the right squamous bone, dividing here into 3 smaller 
lines of fracture, one of which ran obliquely downward into the right mas- 
toid area, while the other two extended forward into the lower portion of 
the right parietal bone and the upper portion of the right squamous bone 
and here ended (Figs. 191 and 192). The dura had not been torn by the 
fracture except in the occipital area just to the right of the median line, 
and it was by means of this channel that the infective process of the occipital 
hematoma had extended intradurally and the diffuse meningitis had resulted. 
The tissues of the right subtemporal decompression were not involved. The 
posterior fossa subtentorially was filled with the purulent secretion which 
had extended both forward into the middle fossa and also downward into 
the spinal canal ; the upper portions of the cerebral cortex were not involved. 
Ventricles contained a small amount of purulent secretion (bacteriological 
report — "streptococci"). There was no gross hemorrhage or cortical lacera- 
tion found. 

Remarks. — This case-history is interesting chiefly from 2 standpoints: 
apparently this is the exceptional and very rare case of severe brain injury 



IN NEWBORN BABIES AND CHILDREN 637 

producing all of the symptoms and signs of a medullary compression, and 
then the rapid onset of a medullary edema in the rapidly rising temperature, 
pulse- and respiration-rates and the quick lowering of the blood-pressure ; 
the operation of subtemporal decompression and drainage is performed in 
the forlorn hope that an immediate lowering of the high intracranial pressure 
might make it possible for this patient to recover from the medullary edema 
— and the patient does make an excellent operative recovery. 

The second and the most unfortunate point in this case-history is the 
rapid development of an acute diffuse purulent meningitis within a period 
of 12 hours — the apparent onset so rapid and overwhelming that numerous 
streptococci are found in the cerebrospinal fluid at lumbar puncture as soon 
as the temperature had suddenly increased to 105.6°, and yet there had 
been apparently no warning sj^mptoms and signs in order that this most 
dangerous condition could have been anticipated or at least retarded. The 
explanation of this lies most probably in the fact that the infective process 
had entered the posterior fossa subtentorially and had rapidly affected the 
medulla, extending downward into the spinal canal within several hours and 
then forward into the middle fossa. In this manner, the cerebral cortex was 
not involved until late in its progress and therefore there had been few if 
any warning symptoms and signs. The almost immediate rigidity of the 
neck and the positive Kernig test are also explained by the early descent of 
the infective process into the spinal canal. 

The importance of draining, or at least, aspirating hematomata which 
overlie a fracture of the vault, and especially if a tear of the underlying 
dura is present, is well illustrated by this patient ; this is particularly true 
if the overlying scalp is contused and thus its resistance to infection lowered. 
If this drainage precaution of the occipital hematoma had been afforded 
to this patient it is very probable that an excellent recovery, both of life 
and of normality, would have been obtained. 

The pupillary changes in this patient are interesting in that the early 
dilatation of the right pupil was the paralytic result of high pressure over 
the right cerebral cortex, and the initial contraction of the left pupil was 
due to the irritative effect of a lower pressure upon the left cerebral cortex ; 
when this intracranial pressure had so increased that the pressure over the 
left cerebral cortex had equalled or approximated that over the right cere- 
bral cortex, then the left pupil also became dilated ; upon the operative relief 
of this high intracranial pressure, the pupils returned to their normal size. 

Case 174. — Acute severe brain injury associated with a compound frac- 
ture of the vault and of the base and with large subdural hemorrhage ; 
signs of extreme intracranial pressure producing medullary compression 
and the early signs of medullary edema. Bilateral decompression and 
drainage. Death; autopsy. 

No. 487. — Henry. Four years. U. S. 

Admitted January 11, 1916. Polyclinic Hospital. 

Operations January 11, 1916 — 1 hour after admission. Bilateral decom- 
pression and drainage. 

Died September 11, 1916 — 4 hours after operation. Acute medul- 
lary edema. 



638 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Family history negative. 

Personal history negative. 

Present Illness. — While climbing an icy fire-escape, child fell to the 
ground—a distance of 2 stories; immediate loss of consciousness; patient 
was immediately carried to the hospital by the mother. 

Examination upon admission (15 minutes after injury). — Temperature, 
98.4° ; pulse, 54; respiration, 14; blood-pressure, 118. Unconscious and in 
mild degree of shock. Over the right occipital area was a compound frac- 
ture of the underlying bone from which macerated cerebral tissue and blood 
were oozing. Profuse bleeding from mouth and both ears ; marked mastoid 
ecchymoses. (The pulse- and respiration-rates were so irregular and slow 
and the period of apncea so prolonged at times — 30 seconds and even longer — 
that a pulmotor was used after attempting artificial respiration for several 
minutes ; the general condition slightly improved. ) Pupils dilated and react 
to light sluggishly. Reflexes all abolished. Fundi — retinal veins enlarged; 
nasal margins of optic disks obscured by edema. Lumbar puncture — bloody 
cerebrospinal fluid under high pressure (approximately 20 mm.). 

Treatment. — For fear that an early medullary edema would be precipi- 
tated by the high intracranial pressure which was already producing the 
typical signs of a medullary compression, an immediate subtemporal decom- 
pression and drainage was considered advisable in the hope that the lower- 
ing of this increased intracranial pressure would permit the child to recover. 
While the operating-room was being prepared, the condition of the child 
became worse in that the pulse-rate began to ascend and the respiration- 
rate also, so that by the time it was possible to start the operation the 
pulse- and respiration-rates were 68 and 18, respectively, while the blood- 
pressure had descended to 112 — the usual signs of an incipient medullary 
edema following a severe compression of the medulla ; it was thought, how- 
ever, that the immediate lowering of the intracranial pressure might be 
sufficient to retard and even prevent the progress of the medullary edema, 
and therefore the operation was performed. 

Operations (1 hour after admission). — (No anesthesia being necessary.) 
First. Right subtemporal decompression : usual incision, bone removed, and 
no complications. Dura very tense, bulging and bluish; upon incising it, 
dark syrupy blood spurted to a height of at least 3 feet ; dural opening quickly 
enlarged and the swollen hemorrhagic brain protruded through the dural 
incision — the cortex rupturing in the lower portion of the operative expos- 
ure. Much dark free blood welled out of opening, but the hemorrhagic cere- 
bral cortex did not pulsate. An attempt to tap the right lateral ventricle in 
order to lower the intracerebral tension was not successful. To permit a 
greater relief of the intradural pressure, a left decompression was now per- 
formed. Usual closure with 2 drains of rubber tissue inserted. (It was 
observed that the right pupil which had been equally dilated with the left 
now became contracted and thus indicating that the paralytic compression 
over the right cerebral hemisphere had been changed by the right subtem- 
poral decompression to an irritative one and thus the dilatation of the right 
pupil became a contraction of it ; the left pupil, however, remained dilated 
as before. Patient regained semiconsciousness for several minutes, but 



IN NEWBORN BABIES AND CHILDREN 



639 



UNE.5 OP 

FRAtTUR 



was unable to answer questions; the pulse, however, continued to ascend 
and was now 76.) 

Second. Left subtemporal decompression and drainage : usual vertical 
incision, bone removed, and no complications ; dura tense and bluish and 
upon incising it, almost pure blood welled out, revealing a tense swollen 
hemorrhagic cortex which tended to protrude but did not rupture ; no cortical 
laceration or large cortical hemorrhage observed. Much free blood and cere- 
brospinal fluid escaped so that at the end of this operation the cortex pulsated 
slightly. Usual closure with 2 drains of rubber tissue inserted. Dura- 
tion, 1 hour. 

Post-operative Notes. — At the end of the operation, the pulse- and res- 
piration-rates had ascended 
to 84 and 26, respectively, 
the temperature to 100°, 
while the blood-pressure had 
descended to 106; within 2 
hours the pulse- and respira- 
tion-rates had ascended to 
110 and 32, respectively, the 
temperature to 103.8°, and 
the blood-pressure had de- 
creased to 98. This condition 
of acute medullary edema 
rapidly progressed so that 
within one-half hour before 
death (4 hours after oper- 
ation), the clinical chart 
was: Temperature, 106.8°; 
pulse, 144 ; respiration, 38 ; 
blood-pressure, 92 — a death 
typical of medullary edema, 

Autopsy. — A depressed 
fracture of right occipital 
bone — the depressed area 
being 2 cm. in diameter; a 
linear fracture extended downward and forward into the posterior rim of 
the foramen magnum and then continued forward from the anterior portion 
of the foramen magnum along the right margin of the basilar process to the 
sella turcica where the line of fracture divided — one extending into the right 
petrous bone and the other across the sella turcica into the left petrous bone 
(Fig. 193). Both tympanic membranes had been lacerated in their posterior 
halves. The right sigmoid sinus had been torn and, besides a large subten- 
torial hemorrhage directly compressing the medulla, there was a layer of 
supracortical hemorrhage due to the tear of several cortical veins as they 
entered the longitudinal sinus. Multiple punctate hemorrhages were present 
in the cortex of both cerebral hemispheres, which were greatly swollen from 
much cerebral edema. The ventricles were negative. 

Remarks. — If this patient could have been operated upon one-half hour 




LINES OF 
FRACTURE. 



Fig. 193. — Extensive basilar fractures of the occipital bone 
extending into the foramen magnum and through both petrous 
bones across the sella turcica in a patient developing an acute 
medullary compression and an incipient medullary edema within 
one hour after the injury. A bilateral decompression and drain- 
age failed to permit a recovery of life. 



640 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

earlier, while the pulse- and respiration-rates were descending rather than 
after the pulse- and respiration-rates had reached their lowest level of 
medullary compression and had begun to ascend, and thus indicating the 
onset of an acute medullary edema, this patient might have had a slight 
chance of recovery — a very slight one, however. As it was, he had no chance 
at all, once the definite signs of an acute medullary edema appeared in the 
rapidly increasing pulse- and respiration-rates, a rising temperature and a 
descending blood-pressure; for these reasons, it would have been better 
surgical judgment to have declined to operate, after it was ascertained that 
these signs of medullary edema had already appeared while the operating- 
room was being prepared. It is very difficult in these patients to refuse to 
operate in the hope that the relief of the high intracranial pressure may 
permit the patient in occasional cases to recover, and yet these patients do 
not recover, whether an operation is performed or not, if the definite signs of 
acute medullary edema have appeared, and therefore no patient in the future 
should be operated upon in this stage of medullary edema. 

The signs of initial shock in this patient were undoubtedly submerged 
by the rapidly increasing intracranial pressure which produced a very early 
medullary compression ; unless a large intracranial vessel is torn as in this 
patient, then it is difficult for the signs of an increased intracranial pressure 
to appear in the presence of severe shock because the lowered general blood- 
pressure of shock will not be able to cause a large intracranial hemorrhage 
to occur, as the increasing intracranial pressure will soon be greater than this 
lowered blood-pressure of shock; in this particular patient, however, the 
initial shock could not have been severe as the result of the cranial injury 
and thus the general blood-pressure was not lowered to any marked degree, 
and so an extensive hemorrhage was possible. 

Case 175. — Acute severe brain injury associated with fractures of the 
vault and of the base and with subdural, cortical and subtentorial hem- 
orrhages; signs of high intracranial pressure and medullary edema. Bilat- 
eral decompression and drainage. Death; autopsy. 
No. 56. — Henry. Five years. White. U. S. 

Admitted September 22, 1913. Muhlenburg Hospital, Plainfield, N. J. 
Kef erred by Doctor E. W. Hedges. 

Operations September 24, 1913 — 38 hours after injury. Bilateral decom- 
pression and drainage. 

Died September 24, 1913 — 2 hours after operations. Acute medul- 
lary edema. 

Family history negative. 
Personal history negative. 

Present Illness. — While running across the road, child was knocked down 
by an automobile ; immediate loss of consciousness ; patient was carried to the 
hospital immediately. Profuse bleeding from nose, mouth and ears, mixed 
with a small amount of cerebrospinal fluid from each ear; in severe shock 
in that the temperature was subnormal, while the pulse- and respiration- 
rates were 140 and 46, respectively. The treatment was the usual expectant 
palliative one with vigorous shock measures ; no return of consciousness. 
Examination in consultation with Doctor Hedges (36 hours after admis- 



IN NEWBORN BABIES AND CHILDREN 641 

sion). — Temperature, 104°; pulse, 154; respiration, 50; blood-pressure, 98. 
Profoundly unconscious ; occasional rales in both lower chests. The pulse was 
rather irregular and weak and the respirations were shallow. Extensive 
contusion over the left f ronto-temporal area ; both orbital and mastoid areas 
ecchymosed. The bleeding from nose, mouth and ears had ceased ; otoscopic 
examination revealed an extensive laceration of each tympanic membrane. 
Pupils — slightly enlarged and react to light sluggishly ; right internal stra- 
bismus. Reflexes — patellar exaggerated, right more than left; no ankle 
clonus but right Babinski ; abdominal reflexes absent. Fundi — retinal veins 
dilated and tortuous ; nasal halves and temporal margins of both optic disks 
obscured by edema, but no measurable papilledema. Lumbar puncture — 
bloody cerebrospinal fluid under high pressure (approximately 24 mm.). 

Treatment. — On account of the high intracranial pressure, it was thought 
that an operative lowering of this increased pressure might offer the child 
a chance of recovery — a mistaken opinion in that it is now recognized that 
once a patient has entered the condition of acute medullary edema as the 
result of extreme intracranial pressure, that patient always dies — operation 
or no operation. 

Operations (38 hours after injury). — (No anesthesia being required.) 
First. Right subtemporal decompression and drainage : usual vertical inci- 
sion, bone removed, and no complications ; upon incising dura which was very 
tense and bluish, almost pure blood spurted to a height of 3 inches and upon 
enlarging the dural opening, a very hemorrhagic and swollen cortex pro- 
truded and almost ruptured from the extreme intradural pressure of supra- 
cortical hemorrhage and cerebral edema. As only slight pulsation of the 
brain was visible at the end of the operation and as the cerebral tension did 
not become markedly less following the escape of much free subdural blood 
and cerebrospinal fluid, it was decided to perform an immediate left sub- 
temporal decompression and drainage. Usual closure with 2 drains of 
rubber tissue inserted. 

Second. Left subtemporal decompression and drainage : usual vertical 
incision, bone removed, and no complications ; a transverse linear fracture 
extended forward along the lower portion of the left parietal bone obliquely 
downward through the anterior area of the left squamous bone and into 
the lower posterior portion of the left frontal bone just above the left 
external angular process; a small amount of extradural hemorrhagic clot 
removed. Dura tense and bluish ; upon incising it, almost pure blood welled 
out and upon enlarging the dural opening a very tense, swollen hemorrhagic 
cerebral cortex tended to protrude but did not rupture ; much free blood and 
cerebrospinal fluid escaped permitting the brain to recede slightly and to pul- 
sate feebly. Usual closure with 2 drains of rubber tissue inserted. Duration, 
55 minutes. 

Post -operative Notes. — Child did not become conscious; the general con- 
dition rapidly became weaker in that the signs of medullary edema advanced 
— the temperature ascending to 106°, the pulse- and respiration-rates to 
160 plus and 54 plus, respectively, while the blood-pressure rapidly descended 
to 86 and lower ; severe pulmonary edema occurred and the child died 2 hours 
after operation — the death of medullary edema. 
41 






642 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



FRACTURi 



rnneTVM, 



Autopsy. — Extensive linear fracture of left vault extended from the pos- 
terior portion of left parietal bone forward and downward into left frontal 
bone and then transversely across both orbital plates ; another fracture of the 
base extended transversely through both petrous bones and the sella turcica 
and into both middle ears (Fig. 194). Multiple punctate hemorrhages 
throughout the cerebral cortex — more over left cerebral hemisphere and 
much free subdural blood subtentorially directly compressing the medulla 
itself. No intracerebral or ventricular hemorrhage. 

Remarks. — It was thought that an immediate relief of this high intra- 
cranial pressure might afford this patient his only chance of recovery; 
however, although the patient had survived the severe initial shock in that 
the pulse- and respiration-rates had at first descended after admission to the 
hospital and the temperature had risen from subnormal to 100° — undoubt- 
edly the period of medullary com- 
pression which was overshadowing 
the signs of shock — and as the 
increased intracranial pressure 
was extreme, the patient rapidly 
passed into the stage of acute med- 
ullary edema without having passed 
through the stage of a typical 
medullary compression clinically, 
in that at no time were the pulse- 
and respiration-rates below 140 and 
40, respectively. From the clinical 
history and the condition as dis- 
closed at autopsy, this patient 
would have died — operation or no.. 
operation, and no operation should 
have been performed upon this 
patient in the belief that it offered 
him a chance of recovery, for the 
condition had advanced into the period of acute medullary edema, and 
these patients in this advanced degree of extreme medullary compression all 
die — operation or no operation. It is possible that an earlier operative relief 
of the high intracranial pressure might have prolonged the life of this 
patient if performed while the pulse- and respiration-rates were descend- 
ing, and yet no operation would have been advisable upon this patient 
because the stage of medullary edema appeared before the pulse- and 
respiration-rates had time to descend below 100 and 30, respectively. 

It is rather unusual for the signs of extreme intracranial pressure, as 
disclosed by the ophthalmoscope and the lumbar puncture needle, to have 
occurred so quickly following the cranial injury, and they indicated that 
this extreme intracranial pressure was due to both a profuse hemorrhage 
and cerebral edema. The autopsy findings of extensive hemorrhage subten- 
torially would indicate a possible blockage of the ventricles due to a compres- 
sion of the aqueduct of Sylvius by hemorrhage or edema in addition to the 
direct medullary compression. It possibly would have been better surgical 




Fig. 194. — Extensive linear fractures of both 
petrous bones and both orbital plates in a patient 
having an extreme intracranial pressure due to sub- 
dural and subtentorial hemorrhage — precipitating 
an acute medullary edema ; a bilateral decompression 
naturally failed to benefit the patient after the con- 
dition of medullary edema had appeared. 



IN NEWBORN BABIES AND CHILDREN 643 

judgment if the ventricles had been tapped at the first decompression and 
any blocked cerebrospinal fluid withdrawn and thereby a lowering of the 
cerebral tension obtained. It must be remembered, however, that no opera- 
tion should have been advised upon this patient on account of his gen- 
eral condition, and that this patient was in one of the two periods when 
no patient should be operated upon — that is, the period of acute medullary 
edema ; the other period in these cases when no operation should be performed 
is that of severe initial shock, when the pulse-rate is over 120, and even 110. 
The extensive fractures of the skull, as disclosed at autopsy, indicate the 
severity of the cranial injury but in no manner lessen the chance of the 
patient's recovery — rather aided it by affording and facilitating the drain- 
age of the hemorrhage and the excess cerebrospinal fluid of the acute 
cerebral edema. 



CHAPTER XIV 
Chronic Brain Injuries in Children Occurring at the Time of Birth 

the condition of cerebral spastic paralysis in children with or without 
marked mental impairment ; observations regarding the operative 
treatment of selected cases due to an intracranial hemorrhage at 
the time of birth. 

Within the past five years, a distinct advance has been made in the diag- 
nosis and treatment of the condition of cerebral spastic paralysis in children. 
It can now be ascertained with a high degree of accuracy whether the condi- 
tion is due to a lack of development of the cerebral cortex and the pyramidal 
tracts, to a former meningoencephalitis with resulting destruction of the cor- 
tical nerve cells and a thrombosis of the vessels supplying these cells, or to the 
result and presence of an intracranial hemorrhage at or near the time of 
birth ; cerebral embolus is a less frequent factor, whereas to lues, as demon- 
strated by the Wassermann examination of both blood and cerebrospinal 
fluid, including a cell count of the latter and in suspected patients the blood 
examination of both parents, can only be attributed less than 2 per cent, 
of the patients (1.7 per cent.). The following observations are based upon 
the examination of 1922 children up to January 1, 1919, having in varying 
degrees the condition of cerebral spastic paralysis. 1 

It is rather instructive to trace the recent history of this condition. In 
1843, Mr. W. J. Little, of London, in his first monograph upon cerebral spas- 
tic paralysis in children or the now so-called Little's disease, and entitled 
' ' Deformities of the Human Frame, ' ' stated that the condition was due to 
an impairment of nerve tissues resulting from their lack of development, 
and also to an earlier meningitis ; a few cases following difficult labor were, 
in his opinion, the result of an intracranial hemorrhage at birth. 2 

It is interesting to note that in his second monograph upon spastic 
paralysis, published in 1862 (just nineteen years later), and entitled "On 
the Influence of Abnormal Parturition, Difficult Labors, etc., upon the Mental 
and Physical Condition of the Child," 3 he stated that, in his opinion, almost 
75 per cent, of these cases were the result of an intracranial hemorrhage. 
Recent study of this subject with the more accurate methods of modern 
examination confirms the belief of Mr. Little that about 60 per cent, of these 
cases of cerebral spastic paralysis occurring in children, with or without 
marked mental impairment, are due to an intracranial hemorrhage at the 
time of birth, while the remaining 40 per cent, result from a lack of develop- 
ment of the cerebral cortex or its pyramidal tracts, and also from an earlier 
meningo-encephalitis following infectious diseases, such as cerebrospinal 
meningitis, measles, scarlet fever, and whooping cough. 

The condition of spastic paralysis in children results most frequently 
1 A preliminary report of this work was made in the Journal of the American Medi- 
cal Association-, May 13, 1916. 

2 The Lancet, vol. i, p. 350 (December 16, 1843). 

3 Obstetrical Transactions, vol. iii, p. 293 (1862). 

644 



OCCURRING AT THE TIME OF BIRTH 645 

from a lesion of the brain occurring before birth, during birth, or shortly 
after birth. It is characterized by more or less complete paralysis of the part 
affected, and is associated with a stiffness or spasticity, depending upon the 
extent of the involvement of the pyramidal tracts; this hypertonicity pro- 
duces muscular contractures and deformities, usually flexor in type, with a 
corresponding overstretching of the opposing muscular groups, usually the 
extensors. In mild cases, however, the spasticity may be so slight as to cause 
little or no deformity, but merely an awkwardness of the part affected. 
Frequently athetoid movements of the arms and legs may be observed, 
and epileptiform attacks, commonly of the Jacksonian type, may occur. In 
a large percentage of these patients as the children grow older, not only 
do the spasticity and its resulting contractures increase, but also their men- 
tality becomes impaired, and this impairment continues until the child may 
be considered a defective or, still further, an imbecile, and only too frequently 
an idiot. This mental impairment in the patients having had an intracranial 
hemorrhage at birth is, in most of the cases, due to the presence of the 
resulting increase of the intracranial pressure ; as the child grows older the 
mental impairment becomes more and more marked as the result of the long- 
continued pressure upon the cerebral cells, whereas in the cases due to a 
simple lack of development, they do not become worse mentally but rather 
do they improve as the result of training, exercise,, etc. 

One of the most common lesions of the brain producing spastic paralysis 
is that of intracranial hemorrhage of the newborn. It is of venous origin 
most frequently, especially the veins overlying the cerebral cortex and the 
venous tributaries of the longitudinal sinus, and in the more extreme cases 
even the longitudinal sinus itself may be ruptured; the overlapping of the 
parietal bones during parturition is the common cause for the injury to the 
sinus. Naturally, the use of high forceps in difficult labor is an important 
causative factor in a large number of cases. However, any prolonged diffi- 
cult labor increasing the venous stasis and partial asphyxia of the child may 
be sufficient to rupture the delicate vessels overlying the cortex of the brain, 
and in this way a hemorrhagic clot forms over the surface of the cortex. In 
some patients the hemorrhage is cortical or subcortical, and therefore, in these 
cases, direct injury and damage are done to the cortex itself — even a destruc- 
tion of the cortical nerve-cells and their fibres — whereas in the usual cases in 
which the hemorrhage occurs upon the cortex rather than within the cortex. 
any cerebral damage is the result of the pressure of the overlying clot 
and not a primary destruction of the cortex itself ; i.e., if it were not for the 
pressure of the overlying hemorrhagic clot, the cortex would not be damaged 
at all, and its nerve-cells would be able to function normally ; on the other 
hand, if the hemorrhage is in the cortex or is subcortical, then a real destruc- 
tion of cerebral tissue occurs, and, once destroyed, there is naturally 
no regeneration. 

According to the extent and pressure of this hemorrhagic clot upon the 
cortical surface do we find clinically the signs of such interference of the 
pyramidal tracts; if over the upper portion of both motor areas, then both 
legs are affected, and a spastic paraplegia results; if over the upper two- 
thirds of both motor tracts, then both the arms and lesrs are involved and 



646 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

a spastic diplegia results, whereas if the entire motor area of both cortical 
hemispheres is compressed, then the extreme form of spastic diplegia results 
— legs, arms, throat, and face all affected ; these extreme cases are the most 
pitiful ones and, fortunately, they rarely live beyond the age of puberty. 
In the majority of these spastic patients, however, the hemorrhage extends 
over one cortical hemisphere alone, the other hemisphere remaining unim- 
paired, so that a spastic paralysis of the leg or arm occurs opposite to the 
hemisphere affected ; if the hemorrhage extends only over the upper portion 
of the motor area, then a monoplegia of the opposite leg results, and if over 
the upper two-thirds of the motor area, then a spastic paralysis of both the 
arm and leg, and if over the entire motor area, then a total spastic hemiplegia 
of the opposite side of the body occurs. The upper portion of the motor area 
is usually more compressed than the lower portion because the hemorrhage is 
here greater, and as the clot extends downward over the cortex it rapidly 
thins, so that we may have a marked, spastic paralysis of the leg, and yet the 
arm be but slightly affected — merely an awkwardness, and the face not at all 
involved. Then, again, absorption of the clot is a most important factor 
in lessening the extent of the paralysis ; in some cases of mild hemorrhage the 
clot may be entirely absorbed, only a few fibrous strands remaining as evi- 
dence of its existence; these are the patients that later may develop epi- 
lepsy in its various forms and show other signs of cortical irritability 
and instability. 

In these cases of intracranial hemorrhage, whether in children or in 
adults following a cranial injury, unless the hemorrhagic clot depresses 
the motor area of either hemisphere, or interferes with the pyramidal 
tracts, then there will be no paralysis, and it is possible for large intracranial 
hemorrhages to occur, and yet there is no resulting paralysis unless the 
motor tract is involved ; that is, the impairment of the special sense and of 
the mentality may overshadow the paralysis, and may even exist alone. In 
this manner, it is possible for the impairment of the mentality to be the chief 
complaint. However, as in adults with intracranial lesions, a definite dis- 
turbance of even the more silent areas of the brain tends to increase the deep 
reflexes of the extremities, and if the motor tracts are still more affected, 
then a definite spasticity results. 

The treatment of the condition has been a most discouraging one — so 
much so that the diagnosis of Little 's disease implied a hopeless condition ; 
these patients have been the bane of treatment not only to the general prac- 
titioner, but to the neurologist and to the orthopedist ; apparently very little 
effort was made to differentiate the three causes of the spasticity, in that 
the condition was believed to be a hopeless one in any event. The treatment 
has usually consisted in the older patients of institutional care, general 
hygienic measures, massage, muscle training, and the various methods of 
physical and mental training; nerve resections and their modifications; if 
deformities had occurred, then their correction by tendon lengthenings and 
the application of braces ; some improvement has been obtained in the lack of 
development cases by ductless gland therapy, but those cases due to a 
former meningo-encephalitis and frequently associated with convulsions, and 
that large group of cases due to an intracranial hemorrhage — the treatment 






OCCURRING AT THE TIME OF BIRTH 647 

of these patients has been most discouraging, as the spasticity, if lessened, 
would return within one year. 

Naturally in the cases due to a lack of development of the cortex and its 
pyramidal tracts, and also those cases resulting from an earlier meningo- 
encephalitis with destruction of cortical nerve-cells, no cranial operation 
could be of any value — there being a defective development, and even loss 
and destruction of nerve tissue. After it had been demonstrated conclu- 
sively that the condition of microcephalus was due to a lack of development 
of cerebral tissue rather than to a premature closure of the sutures of the 
skull, and that naturally any cranial operative procedure upon these patients 
could be of no possible benefit (as shown by the operations of Lannelongue 
and others) , the idea of a cranial operation as an aid in the treatment of cere- 
bral spastic paralysis was therefore discarded and remained discredited until 
the last few years. This lack of differentiation of the three main causes of 
cerebral spastic paralysis permitted those cases due to an intracranial 
hemorrhage to escape serious attention, so that they, too, were considered 
as being hopeless conditions; it was believed that when an intracranial 
hemorrhage did occur at birth as the result of a difficult labor, the hemor- 
rhage caused a primary destruction of brain tissue and therefore no regenera- 
tion was possible, so that in these patients, too, no cranial operation could be 
of any possible benefit. 

A number of years ago, there were many theories regarding the cause of 
cerebral spastic paralysis. These patients were usually grouped among the 
mentally defective and classified as defectives, imbeciles and idiots, with 
or without paralysis. Those cases of spastic monoplegia or hemiplegia, 
without marked signs of mental impairment, were very puzzling. For many 
years, it was believed in cases of imbeciles with unusually small heads, that 
their mental impairment and possible spastic paralysis were due to prema- 
ture closure of the sutures of the skull which prevented the normal develop- 
ment of the brain — that is, the skull was too small for the brain. The truth 
was not ascertained until later that the skull did not enlarge because the brain 
itself did not enlarge and develop normally — that is, the size of the cranium 
is an index of the size of the brain — only quantitatively, however, not qualita- 
tively. Many cranial operations were devised to offset this supposed prema- 
ture closure of the sutures of the skull, and so allow the brain to develop — 
as they thought it would. Trephine openings of various sizes were made 
in the cranial vault in the hope that the brain would have more room to 
develop ; at times the dura was incised, but more frequently this membrane 
was left intact, There was no selection of patients made — the fact that the 
cranium was small was considered sufficient cause for the undeveloped brain ; 
whether there was present an increased intracranial pressure or not was not 
considered nor ascertained before selecting their cases for operation ; and yet. 
it is surprising that a few of their patients did improve slightly, showing that 
these few cases, at least, must have had an increased intracranial pressure 
resulting from a hemorrhage, and that even the inadequate operation was 
sufficient to produce some improvement, Efforts were made to separate 
the sutures of the skull under the impression that they had united prema- 
turely and this tremendous operation was repeatedly performed with little 



648 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

or no result. As the dura in the extreme cases of spastic paralysis due to 
intracranial hemorrhage may be fibrosed and thickened three and four times 
its normal size, so that it becomes inelastic as in adults, it would have been 
possible to remove the entire vault of the skull, and yet if the dura were not 
incised, there could be no relief of pressure obtained nor any enlargement 
of the intradural capacity possible; that is, to obtain any decompressive 
effect, the dura must always be incised and allowed to remain open; to 
resuture it necessarily prevents any permanent relief of the pressure. 

During the past few years, the treatment has been directed toward an 
improvement of the results of the central intracranial lesion upon the 
extremities and it has been a most discouraging field of work. The opera- 
tions which have been used in the past and are still being used to improve the 
condition of spastic paralysis, namely, tenotomies, tendon lengthenings, 
sections of the posterior nerve roots, alcohol injections of peripheral nerves, 
nerve resections and other operations, are of only temporary benefit, and it 
is very rare to see a patient in whom the spasticity has not returned in some 
degree within one year. In all of the patients treated by the operations 
just mentioned during the past five years in our clinic, the spasticity began 
to return within one year after the operation. 

Tenotomies have been unsatisfactory. Tendon lengthenings alone are 
satisfactory in only very mild cases. Foerster's operation for sectioning 
of the posterior nerve roots of the spinal cord is advocated merely to lessen 
the irritability and the instability of the cortex of the brain by decreasing 
the number of afferent stimuli reaching the spinal cord, and also to affect the 
reflex mechanism of the spinal cord; besides being a rather formidable and 
long operation for a child, the lessening of the spasticity is only temporary, 
few cases being reported improved longer than one year ; our experience with 
seven patients has been the same. The injection of alcohol into the periph- 
eral nerves (the Allison and Schwab operation) produces immediate paralysis 
and a temporary relief from spasticity; in our experience of thirty-one 
patients, however, the spasticity has returned within one year. With nerve 
resections (Stoeffell 's operation) , we have had no experience. Besides in these 
operations, we do not in any way ' ' get at ' ' the primary cause for the spastic 
paralysis, namely, the lesion of the brain, but they are merely peripheral 
operations to relieve the spasticity temporarily, in the hope that, before 
the recurrence of the spasticity, sufficient power will have returned to the 
opposing muscular groups to re-establish the muscle balance. 

Little, if anything, had been accomplished in improving permanently the 
condition of spastic paralysis, and the following observations are offered in 
the hope that they may lead to a more satisfactory solution of the treatment 
of these most pitiful patients. Attention was first centered on the importance 
of relieving the increased intracranial pressure as a means of lessening the 
spasticity and improving the mentality of selected patients, by a decom- 
pression operation performed by me in June, 1913, at the Nassau Hospital, 
Garden City, Long Island. The patient, referred by Doctor L. B Rogers, 
was a first child, nine years of age, who was apparently normal in every way 
after an easy delivery until the ninth month of age, when he suddenly had 
a series of epileptic attacks ; after these convulsive seizures had subsided, it 



OCCURRING AT THE TIME OF BIRTH 649 

was observed that there was a total left hemiplegia with exaggerated re- 
flexes ; the left arm and left leg became spastic and gradually assumed the 
flexor contractures so typical, in these spastic patients. Three years ago, the 
patient had another series of convulsions and since that time these convulsive 
seizures of varying severity have continued almost daily ; the mental impair- 
ment was moderate. Every method of treatment had practically been given 
up as useless. Last June, another series of convulsions began and during the 
four days preceding my examination of the patient, 302 attacks had occurred ; 
the child was in a condition of status epilepticus — one convulsion following 
another; the almost continuous administration of chloroform was of little 
value. In addition to the typical left spastic hemiplegia, the patient had at 
this examination double ' ' choked disks ' ' as revealed by an ophthalmoscopic 
examination — that is, a high intracranial pressure, the pulse was 54 and 
the respiration 8, and oxygen was being used (as a last resource) . I advised 
a right subtemporal decompression in the hope that a relief of the increased 
intracranial pressure might improve the condition of the patient. No anes- 
thetic was necessary — the patient being unconscious ; upon incising the 
dura, which was exceedingly tense, the cerebrospinal fluid spurted to a height 
of six inches ; the cortex was edematous and swollen, and upon enlarging the 
opening upward, a fibrous mass, apparently the residue of an old cortical 
hemorrhage, was exposed lying upon the cortex and extending upward 
beneath the margin of the decompression opening. As the condition of 
the child was bad, I decided to remove the mass at a later operation. Owing 
to the mere relief of the intracranial pressure, the child became conscious 
at the end of the operation and an uneventful recovery occurred — the child 
leaving the hospital upon the eleventh day post-operative. The striking- 
feature of the case, however, was the gradual lessening of the spasticity 
and the contractures of the face, arm and leg, and this improvement con- 
tinued until the child began using the leg freely and the left hand and arm 
for picking up articles for the first time in its life ; there was also a definite 
mental improvement. 

The thought then occurred : Why not perform a cranial decompressive 
operation in those selected cases of cerebral spastic paralysis dite to a possible 
hemorrhage upon the brain and showing signs of an increased intracranial 
pressure ? The eyes, therefore, of spastic children were examined carefully 
with an ophthalmoscope for signs of an increased intracranial pressure. It 
was very surprising to ascertain that of the patients examined — a large num- 
ber did show mild though distinct signs of an increased intracranial pressure 
— that is, a dilatation of the retinal veins, and a hazy edematous blurring of 
the nasal margins of the optic disks ; many of them showed even mild signs of 
old secondary optic atrophy — rather whitish disks and the physiological 
cups shallow from scar tissue formation. Doctor Benjamin Farrell and I 
then began to select for operation such patients having these definite signs 
of increased intracranial pressure from the various orthopedic clinics — 
especially the extreme cases and the ones who had received the treatment 
of tenotomies, tendon lengthenings, alcoholic injections, braces, daily mas- 
sage and exercises — many of them having been patients during a period o\" 
years! and with little or no permanent improvement. 



6 so DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

During the past six years (until January 1, 1919), I have had the oppor- 
tunity to examine personally 1922 children having the condition of cerebral 
spastic paralysis of the diplegic, hemiplegic, and rarely of the monoplegic 
type; their ages varied from two hours to twenty-five years — the average 
being four years. In addition to the history and physical findings, there were 
routine examinations of the fundi of the eyes with the ophthalmoscope in 
every patient, and a measurement of the pressure of the cerebrospinal fluid 
at lumbar puncture. This latter test is the most accurate method now known 
for ascertaining the pressure of the cerebrospinal fluid by means of the 
spinal mercurial manometer ; the normal pressure is 5 to 9 mm. of mercury, 
whereas in the patients having an increased intracranial pressure due to a 
former intracranial hemorrhage the column of mercury may rise to 20 mm. 
and higher, and thus the definite increase of the intracranial pressure is 
determined. The ophthalmoscopic examination of the fundi is a less delicate 
test of increased intracranial pressure ; naturally, the papilledema and 
"choked disks" of intracranial tumors and internal hydrocephalus 4 are 
not to be found in these cases of cerebral spastic paralysis due to a former 
hemorrhage, as the intracranial pressure in these patients is not sufficiently 
high to produce these extreme results of high pressure, but their milder 
signs are exhibited in the blurring and edematous obscuration of the optic 
disk margins, and frequently the entire nasal halves of the disks ; the retinal 
veins are dilated, frequently tortuous, and their walls thickened with 
fibrous tissue formation. 5 In conditions of myopia, a similar appearance is 
also frequently found, but if the measurement of the pressure of the cerebro- 
spinal fluid by the spinal mercurial manometer confirms the ophthalmoscopic 
findings of an increased intracranial pressure, then there can be no doubt 
of its presence. 

Of the 1922 children examined, having the condition of cerebral spastic 
paralysis, only 368 of them showed the definite signs of an increased intra- 
cranial pressure, and therefore only these patients (about 19 per cent.) were 
the ones diagnosed as being due to an intracranial hemorrhage, while the 
remaining 1554 patients, or 81 per cent, of the total number of the patients 
examined, did not show the signs of an increased intracranial pressure and 
were therefore classified as being due to a lack of development of cerebral 
and pyramidal tract tissues, a former meningo-encephalitis, or to an intra- 
cranial hemorrhage which was not of sufficient size to produce the signs of 
an increased intracranial pressure in the fundi of the eyes or in the measure- 
ment of the cerebrospinal fluid at lumbar puncture; I believe there are 
many cases of latent intracranial hemorrhage where the absorption of blood 
is sufficient to cause later very little increase of the intracranial pressure, 
and therefore the diagnostic methods now used are not sufficiently accurate 
to detect the existence of a former hemorrhage. It must also be remembered 
that patients having had a meningo-encephalitis and associated with per- 
sistent convulsions frequently show signs of an increased intracranial 
pressure due to the edematous wet condition of the brain — that is, a mild 

4 American Journal of Medical Sciences, April, 1917. 

5 Archives of Ophthalmology, No. 4, 1917. 






OCCURRING AT THE TIME OF BIRTH 651 

condition of external hydrocephalus; in these patients, the history is most 
helpful in differentiating- them from the ones due to hemorrhage. 

The history of these 1922 patients has been most instructive : Of the 
918 children whose physical and mental impairments were diagnosed as being 
the result of lack of development of cortical or pyramidal tract nerve tissues, 
only 73 were not premature babies, and only 89 were not born after a number 
of pregnancies ; that is, the impairment of nerve tissue in these patients was 
due either to insufficient time for its proper development and growth, as in 
the premature babies of the seventh and eighth month, or to a less active 
growth of the nerve-cells themselves, as occurs in children following a large 
number of pregnancies, where the mothers become malnourished and physi- 
cally less vigorous. Naturally, none of these children showed signs of an 
increased intracranial pressure. Syphilis has been demonstrated to be a 
possible active etiological factor in only 31 children (that is, 1.6 per cent.) 
of the entire number of 1922 patients examined ; a Wassermann test both 
of the blood and cerebrospinal fluid has been made in each child ; in doubtful 
cases, a cell count of the cerebrospinal fluid has also been utilized and also 
the blood of the parents examined ; in four instances the cerebrospinal fluid 
of the parents was examined, but with negative results. 

Of the 608 cases diagnosed as being the result of a former meningitis 
and meningo-encephalitis, the history of an acute illness associated with high 
fever was present in each patient except 77 ; convulsions had occurred in all 
but 45 of them. In most of them, the child had been apparently normal until 
the date of the acute illness, whether it was ten days after birth or two or 
three years ; following the sickness, it was noticed that one side of the body 
could not be used so well as the other, and then gradually a stiffness of the 
arm and leg occurred ; the convulsions persisted in 327 of these patients, and 
they were all very unstable children emotionally. When the spastic paralysis 
followed an acute infectious disease, such as measles, whooping cough and 
scarlet fever, these cases were usually of the hemiplegic type, and undoubt- 
edly many of them were of thrombotic origin ; convulsions usually occurred 
at the height of the fever, but in many patients they did not continue for 
more than several days to two or three weeks. Those cases following cerebro- 
spinal meningitis were usually of the diplegic and paraplegic types, and in 
several of them there were mild signs of an increased intracranial pressure, 
undoubtedly due to a wet, edematous condition of the brain — a mild con- 
dition of external hydrocephalus with and without convulsions. 

Of the total number of 1922 children examined, only 368 of them were 
diagnosed as being the result of an intracranial hemorrhage at or near 
the time of birth ; that is, 19 per cent, of the patients having the condition 
of cerebral spastic paralysis showed definite signs of an increased intra- 
cranial pressure, and these are the patients, and only the ones, that can be 
improved by lessening this increased intracranial pressure as early as pos- 
sible after the hemorrhage has occurred. 

Let me emphasize (for fear of being misunderstood'), first, that we are 
not operating upon the mentally deficient, the constitutionally inferior and 
idiots in the hope of restoring them to a normal mentality: and secondly, 
that we are not operating upon microcephalic children in the belief that the 



652 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

brain will develop and become normal by enlarging th^ cranial capacity; 
and thirdly, that we are not operating upon cases of spastic paralysis due 
to a lack of development and malformation of the cortex of the brain and 
the pyramidal tracts — cases forming at least one-half of the total number 
of patients having spastic paralysis — the so-called Little 's disease, in which 
a cranial operation will do no good and from the very pathology of the condi- 
tion a cranial operation can be of no benefit to the patient. On the other 
hand, we are operating upon those cases of cerebral spastic paralysis giving 
a history of difficult labor with or without instruments, and upon ophthal- 
moscopic examination the definite signs of an increased intracranial pressure 
are to be seen in the fundus of the eye, and confirmed by the measurement 
of the pressure of the cerebrospinal fluid by means of the spinal mercurial 
manometer — i.e., only those cases of cerebral spastic paralysis which show 
definite signs of increased intracranial pressure, whether this condition is 
associated with impaired mentality (and it very frequently is as the result of 
prolonged pressure upon the cortex of the brain), or whether the size of 
the head is unusually large or small; if, in these latter patients, there is an 
increased intracranial pressure, then that pressure should be relieved in the 
hope that the spasticity will be lessened, and the mentality be improved. 
Naturally, the most satisfactory and desirable patients for operation are 
the ones with no impairment of the mentality, but these patients are rare 
when there has been a prolonged increase of the intracranial pressure ; much 
more commonly do we find a more normal mentality in the patients having 
lack of development and malformation of the pyramidal tracts, unless 
very extensive. 

Naturally, the earlier the diagnosis is made after birth and an operation 
performed to relieve the intracranial pressure, just so much better is the 
ultimate prognosis ; in the newborn infants under ten days of age, not only 
will repeated lumbar punctures and spinal drainage and if not successful, 
then the cranial decompression lessen the intracranial pressure directly, but 
they will afford a means of drainage of the blood, whereas in the older 
children the cranial operation is performed merely to offset the pressure 
effects of the former hemorrhage ; if possible, its resulting cystic formation 
or fibrous mass is removed, but this can rarely be accomplished, owing to the 
great danger of injury to the underlying cortical nerve-cells. I have now 
performed this operation of cranial decompression and drainage upon 358 
children up to January 1, 1919, with a mortality of 36 ; that is, about 10 per 
cent. Their ages have ranged from two hours to twenty-five years ; fourteen 
babies were operated upon the first day after birth with a mortality of two 
(the hemorrhage being subtentorial and of large amount — producing direct 
pressure upon medulla ) , while nine of the remaining twelve children are at 
the present time apparently normal in every way; eight babies were 
operated upon the second day after birth with no mortality, and five on the 
third day, also with no mortality. Naturally, this early diagnosis and opera- 
tion is the ideal time for the best results to be obtained, for at this early date 
the supracortical blood can be drained away and the cortical nerve-cells be 
thus spared from the superimposed pressure of the hemorrhage. The diag- 
nosis at this early date is easily confirmed by the presence of blood in the 



OCCURRING AT THE TIME OF BIRTH 653 

cerebrospinal fluid at lumbar puncture; the fundi of the eyes rarely show 
signs of pressure at this early date, unless the hemorrhage is very large. 

Some points in the history of these 358 operated patients have been 
most interesting and instructive; only 52 of them were not first children; 
only 17 were not full-term babies ; only 38 were not born with difficulty — 
instruments being used, and, particularly, high forceps in a large percentage 
of them ; only 76 did not have convulsive twitchings immediately after birth, 
and in only 4S children was the spasticity noticed before the eighth month 
after birth. Of these 358 operated patients, 184 were hemiplegic, 41 para- 
plegic, and 111 diplegic ; many of the patients who were operated upon during 
the first year of this work in 1913 were the extreme types of the condition — 
derelicts, as it were, and so badly impaired, both mentally and physically, 
that only a slight improvement, if any, could be expected in the older 
cases ; the average age of the first 65 operated children was six years, and 
many of them had never walked nor talked. Naturally, cases of this age 
and of this extreme type can, at best, be only improved ; their cortical nerve- 
cells have become so impaired from the overlying hemorrhage that any 
marked return of function is very doubtful; and yet, even in some of 
these older extreme cases, the improvement has been most striking; seven 
children, who had never walked, and each of them over eight years of age 
at the time of the operation in 1913, are now walking. 

In the younger children, however, the results have been most gratifying, 
and it is in these patients under three years of age that the greatest amount 
of improvement can be obtained by an early operative procedure. Not only 
has there been a lessening of the spasticity of the arms and legs impaired 
in these patients selected for operation, but there has been a definite ameliora- 
tion of the mental condition of the patients to such a degree that in many of 
the older children their cooperation in the carrying out of the after-treat- 
ment can be obtained ; this is a most important aid in the physical training 
of the child. 

A written permission for autopsy is obtained from the nearest relative 
of each patient (private or ward) before operation; in this manner, if the 
patient should die, then not only will the cause of death be ascertained, but 
the accuracy of the diagnosis and other valuable data for the treatment of 
future patients; of the 36 patients who died, an examination of the brain 
was made in each case, and in all of them, with the exception of two patients 
the diagnosis of an intracranial hemorrhage was confirmed; the autopsy 
of these two patients was most instructive ; the first one did not have an 
intracranial hemorrhage but a very "wet," edematous brain under high pros- 
sure associated with an enlarged thymus, whereas the second patient revealed 
an edematous condition of the brain with numerous adhesions and a whitish 
connective-tissue . formation in the sulci about the vessels — similar to the 
results of a former meningitis. 

Moving pictures have been taken of a large number of these patients 
before operation, and then at intervals of six months following the opera- 
tion; in this manner, the lessened spasticity and the resulting improvement 
of gait can be accurately demonstrated and recorded. 

The Binet mental tests have been used both before and at regular inter 






654 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 




vals following the operation; the mental improvement of many of these 
children has been most impressive. 

METHOD OF OPERATIVE PROCEDURE 

In those cases of spastic paralysis of the hemiplegia, paraplegic, or 
diplegia type with a definite history of difficult labor, with or without the 
use of instruments, and in whom, upon ophthalmoscopic examination, definite 
signs of increased intracranial pressure are shown in the dilated retinal 
veins and a blurring and haziness of the optic disks, especially of their nasal 
halves, and the cerebrospinal fluid at lumbar puncture is under high pressure 
as measured by the spinal mercurial manometer, then a large right subtem- 
poral decompression is performed to relieve the intracranial pressure. If 
the intracranial pressure is extremely high and remains high after the 

operation, a left subtemporal decom- 
pression is performed the following 
week, the operative recovery requir- 
ing only a week or ten days. 

The operation itself is a typical 
subtemporal decompression and con- 
sists of a vertical incision over the 
side of the head, two and one-half to 
three inches in length, extending 
from the parietal crest down to a 
point overlying the zygomatic arch 
and just anterior to the external 
auditory meatus — that is, to the 
lowest level of the middle fossa 
(Fig. 195). The fibres of the tem- 
poral muscle are separated longitudi- 
nally, and then a small opening in 
the squamous bone made by the 
Doyen perforator and burr is en- 
larged by rongeurs to a diameter of two to three inches. The dura is now 
incised in a stellate manner and left open, and by this means of drainage the 
increased intracranial pressure is relieved permanently. The duration of the 
operation should not exceed fifty minutes ; usually it is only forty minutes. 
Absolute hemostasis is essential — the less the loss of blood, the less the shock. 
The loss of a large amount of cerebrospinal fluid should be prevented by 
elevating the head during the operation, and if the post-operative tempera- 
ture exceeds 104°, then the head of the bed should be lowered. This operation 
is not a formidable procedure for one trained in neurological surgery; the 
anesthetic should be administered by an expert. 

The usual pathological findings are definite fibrous or cystic formations 
resulting from a supracortical hemorrhage occurring at birth. These patho- 
logical lesions are treated according to the individual findings — removed, 
punctured, the outer wall of the cyst excised, and very frequently merely 
let alone; that is, more damage to the underlying cortical nerve-cells may 
result by endeavoring to remove the lesion, and therefore it is wiser in many 




Fig. 195. — Sagittal section of the skull of a 
baby of three months of age indicating the re- 
lations of the vertical incision of a right subtem- 
poral decompression. 



OCCURRING AT THE TIME OF BIRTH 655 

patients not to attempt it. The decompressive operation is performed merely 
to offset the local effects of the pressure of this hemorrhage with cystic forma- 
tion and the partial blockage of the excretion of the cerebrospinal fluid by 
lowering the general intracranial pressure and by draining the excess amount 
of cerebrospinal fluid, and consequently lessening the spasticity and mental 
impairment. In 47 patients, the hemorrhagic cyst was cortical and sub- 
cortical and naturally in these patients, the nerve-cells and their fibres must 
have been primarily damaged, so that a marked improvement cannot 
be expected in them. In 84 patients at operation, the supracortical hemor- 
rhagic cyst was visible, and in all of the operated patients the intradural 
pressure was abnormally increased. 

The dura has been thickened, whitish and fibrous in all of the patients at 
operation ; in not one of these patients was the dura transparent. Even in 
babies under one year of age, the dura was frequently of a thickness of 
one-sixteenth of an inch and non-elastic; this fact undoubtedly accounts 
for the lack of bulging of the fontanelles after the first month following 
birth in these patients, in that the supracortical and subdural hemorrhage 
forms a layer of clot over the inner surface of the dura — at times to a thick- 
ness of y s of an inch, and then the organization of this blood-clot causes the 
fibrous thickening of the dura itself due to this connective "scar" tissue 
formation ; not only does the dura become thickened, whitish and non-trans- 
parent, but of the greatest importance to the future cerebral development of 
the child the dura also becomes non-elastic, so that in these patients) there is 
no bulging of the fontanelles and frequently very little pulsation is palpable, 
and the closure of the fontanelles occurs either at the normal time or fre- 
quently earlier than is normal. Ophthalmoscopic examinations and the 
spinal mercurial manometer will, in these patients, register an increase of 
the intracranial pressure, whereas the premature closure of the fontanelles 
and cranial sutures due to conditions of lack of development of the cerebral 
tissues will naturally not produce any of the signs of an increased intra- 
cranial pressure. The appearance of the spasticity being delayed usually 
until the seventh or eighth month after birth in the hemorrhage cases is 
most probably due to the progressive effects of this non-elasticity of the 
dura which prevents the normal development of these children — both physi- 
cally and mentally, whereas immediately after birth the increased intra- 
cranial pressure is compensated, at least temporarily, by the elasticity of 
the dura making possible the bulging at the fontanelles and the separation 
of the cranial sutures. 

This prolonged increase of the intracranial pressure — months and even 
years after the original subdural hemorrhage — is rather surprising, and 
yet the reason for it is obvious. In the mild cases, no doubt there are many 
latent conditions of intracranial hemorrhage at birth where the blood 
escaping into the cerebrospinal fluid supracortically is not of sufficient 
amount to prevent its being absorbed within a few days or weeks at 
most; that is, similar to many adult patients having brain injuries. 
with or without a fracture of the skull, in whom a moderate amount of blood 
from the ruptured intracranial vessels can be absorbed naturally, so that no 
cranial operation of decompression and drainage is necessary and an un- 



656 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

eventful recovery occurs; it should also be remembered in this connection 
that in some of those so-called latent cases of intracranial hemorrhage 
where apparently an excellent recovery has been obtained, yet later in life 
convulsive seizures may occur, and at operation or autopsy there are found 
numerous supracortical adhesions usually associated with an edematous 
cortex — an evidence and result of the former supracortical hemorrhage. 
In the more severe cases, however, of a supracortical hemorrhage at birth, 
it is of such large amount that it cannot be absorbed normally; then later 
do we find not only the definite evidence of its presence in the fibrous or 
cystic formations, in and usually upon the cerebral cortex, but also the 
walls of the cortical vessels and particularly of the cortical veins and 
sinuses are very much thickened and fibrosed (just as the dura itself is 
thickened in the patients having had an earlier supracortical hemorrhage) ; 
this thickening of the vessel walls and the overlying dura is the result of 
the organization of the layer of the supracortical blood, so that the excretion 
of the cerebrospinal fluid through the stomata of exit in the walls of the cor- 
tical veins, sinuses, etc., is thus blocked, and therefore a wet, edematous 
condition of the cortex results— a mild condition of external hydrocephalus. 6 
Just as the condition of hydrocephalus is due in the majority of patients to a 
former meningitis, and if the aqueduct of Sylvius or the foramina of 
Majendie or Luschka are blocked by the meningeal exudate or adhesions, then 
the condition of hydrocephalus interna develops, but if the ventricles are 
not thus blocked yet the condition of hydrocephalus externa may develop on 
account of the meningitis being usually a diffuse process, so that it is very 
probable that the normal stomata of exit for the excretion of the cerebro- 
spinal fluid through the cortical veins and sinuses will have become blocked 
by the meningeal exudate ; in this same manner, a mild external hydro- 
cephalus is not only possible but very liable to result in these conditions of 
supracortical hemorrhage of the diffuse type occurring at or near the time 
of birth (Fig. 196). Therefore, the resulting increase of the intracranial 
pressure in many of these patients having the condition of cerebral spastic 
paralysis is not only due to the direct increase of the intracranial contents 
by the escape of blood upon the cortex and into the subdural space with the 
later fibrous and cystic formations, but also due in very many of the patients 
to a blockage of the normal excretion of the cerebrospinal fluid through its 
channels of excretion — the cortical veins and sinuses. 

The after-treatment consists of the routine orthopedic treatment which 
the patients, with the exception of the newborn babies, had all had before 
operation ; the correction of the deformities by tendon lengthenings or merely 
stretching of the contracted muscles, the maintenance of corrected positions 
through the employment of specially adapted braces, and skilled massage, 
particular attention being given to the weakened and overstretched muscle 
groups ; the usual systematic course in muscle training has been carried on as 
before the operation. Mental training in special schools is most important. 
Naturally, we do not believe that all patients having the condition of cere- 
bral spastic paralysis due to an intracranial hemorrhage should have a 
cranial decompression; in some mild cases tendon lengthenings alone are 

6 American Journal of Medical Sciences, April, 1917. 






OCCURRING AT THE TIME OF BIRTH 657 

sufficient, and this is especially true in the absence of mental impairment. 
But those selected cases of spastic paralysis, particularly of the hemiplegic 
and paraplegic types, which show the definite signs of increased intracranial 
pressure are the ones that can be very much improved by such a procedure. 
In conclusion, I wish to repeat that this is merely a report of the work 
being carried on to improve the condition of selected cases only of cerebral 
spastic paralysis in babies and children. Naturally, the earlier after birth 
the diagnosis of intracranial hemorrhage is made, so that the blood can be 
drained off in fluid form by a simple operative procedure — either by repeated 
lumbar punctures of spinal drainage or by a modified cranial decompression 
and drainage — the better and more normal the child to be obtained ; the 
object of this work is to emphasize! the necessity of earlier diagnosis and 




Fig. 196.— No. 966. Ellen, 8 months of age. An advanced condition of external hydrocephalus resulting 
from an extensive supracortical hemorrhage at the time of instrumental birth; several convulsive seizures 
occurred within the first three days following birth but not associated with an increased temperature; a lum- 
bar puncture at this time removed bloody cerebrospinal fluid but not under high pressure (undoubtedly due 
to the compensatory enlargement of the head which was of normal size at birth). The head gradually en- 
larged after one month of age, most probably due to an increasing blockage of the excretion of the cerebro- 
spinal fluid into the supracortical veins and sinuses as the result of the connective tissue formation and 
organization of the layer of supracortical hemorrhage. A right subtemporal decompression with drainage 
by means of several linen strands at seven months of age has obtained a marked improvement; the ventricles 
were not dilated. 

earlier operations in these selected patients; also the necessity of possibly 
more careful obstetrics, particularly in the use of high forceps when a 
Cesarean section may be preferred. Most of the older; children have really 
been derelicts at the time of operation, and yet, if an improvement can be 
obtained in these older children, surely a much greater improvement is 
possible in the younger children. The operation is by no means a cure — 
except possibly in the newborn infants — and the improvement in our selected 
patients may be only a temporary one, as sufficient time has not yet elapsed 
to permit a definite opinion. But from the pathology of these selected eases 
operated upon and the general continuous improvement which lias resulted 
and is still progressing, I feel justified in. making a report of the work in 
the hope that it may be an aid in the preventive treatment of this very 
pitiful condition. 

Case 176. — Chronic severe brain injury at birth, associated with a 



658 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

depressed fracture of the vault, a right spastic hemiplegia and with convul- 
sive seizures; a definite increase of the intracranial pressure. A modified 
left subtemporal decompression. Excellent recovery. 

No. 64. — Francis. Twenty-six months. White. U. S. 

Admitted April 15, 1914 — 26 months after birth and injury. Polyclinic 
Hospital. Referred b} T Doctor John A. Wyeth. 

Operation April 16, 1914. Left subtemporal decompression and removal 
of depressed area of bone. 

Discharged April 26, 1914 — 10 days after operation. 







Fig. 197. — Depressed fracture of the left parietosquamous area following an instrumental delivery in 
a child two years of age; an increased intracranial pressure associated with a right spastic hemiplegia 
and convulsive seizures. Excellent recovery following a left subtemporal decompression. 

Family history negative ; four older children all living and well. 

Personal History. — Fifth child, nine months pregnancy, difficult labor 
requiring instruments : weight 9 lbs. Immediately after delivery, a large 
depression of the left lower parietal area was observed — the diameter being 
2 inches and its depth about y 2 inch. Xo attempt was made to elevate the 
bony depression, as it was thought that it would disappear itself — like 
many ' ' ping-pong ' ' depressions of the vault of newborn children. Eighteen 
hours after birth, a convulsive twitching of right side of face and of right arm 
occurred and continued every half hour for 2 or 3 minutes ; 28 hours after 
birth, a general convulsive seizure with loss of consciousness followed one of 
these localized convulsive twitchings of the right face and of the right arm ; 



OCCURRING AT THE TIME OF BIRTH 659 

during the following week, five general convulsive seizures occurred and then 
gradually the convulsive twitchings of the right side of face and the right 
arm subsided and did not reappear until a general convulsive seizure oc- 
curred during the tenth month after birth and the last one during the 
eighteenth month after birth — that is, 8 months ago. During this entire 
period, the depressed area of the left parieto-squamous bone remained the 
same. At six months after birth, it was observed that there was a definite 
weakness of the right arm and of the right face; the child did not hold its 
head up until 11 months after birth, did not sit up until 16 months after 
birth and it only began to walk 4 months ago — that is, at 22 months of 
age. During this period there was a definite spastic paralysis of the entire 



"-■%, 



Fig. 198. — Side view of the same patient, havin? a depressed fracture of the left vault and a supra- 
cortical hemorrhage at the time of birth. A left subtemporal decompression afforded almost immediate 
improvement. 

right side of the body — particularly of the right arm and of the right leg, 
which were held in the typically flexed and stiff postures. The child was 
considered normal mentally in its speech and behavior. The treatment of 
the child had consisted of daily massage during the past six months. 

Examination upon admission (26 months after cranial injury ). — Tem- 
perature, 98.6°; pulse, 88; respiration, 26; blood-pressure, 106. A well- 
nourished child. A definite retardation mentally is elicited by the special 
tests; react rather sluggishly. In the left parieto-squamous area over- 
lying the left parietal crest is a definite depressed area of almost 3 inches in 
width and at least one-half inch in depth; no tenderness or pulsation upon 
palpation (Figs. 197 and 198). Typical right spastic hemiplegia involving 
the right arm, the right leg and the cortical type of paralysis of the right 
side of the face; no sensory impairment, however, could be elicited. When 
walking, child drags right leg and walks upon the toes. A definite spinal 
curvature — a right dorso-lumbar compensatory scoliosis. Hearing appar- 



66o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

entry negative. Pupils equal and react to light normally. No strabismus 
or nystagmus ascertained. Reflexes : patellar exaggerated, right more 
than left ; right exhaustible ankle clonus and right Babinski ; abdominal re- 
flexes — right less active than left. Fundi : retinal veins dilated ; nasal mar- 
gins of both optic disks blurred by edema ; the optic disks themselves are 
possibly paler than normal. Lumbar puncture — clear cerebrospinal fluid 
under increased pressure (approximately 16 mm.) ; "Wassermann test was re- 
ported negative later. X-ray (Doctor A. J. Quimby) — "a depression of the 
vault of the left parieto-squamous area — 2 1/ 2 inches in diameter and almost 
2 cm. in depth ; no linear fracture observed. ' ' 

Treatment. — As the increased intracranial pressure appeared higher than 
due merely to the depressed bone, a removal of the depressed area of bone 
was advised by means of a high left subtemporal decompression. 

Operation (April 16, 1914 — 26 months after injury). — A left subtem- 
poral decompression and removal of the depressed area of the vault: the 
usual vertical incision extended one inch higher to the upper edge of the bony 
depression; Doyen perforator and burr used to make a small open- 
ing at the edge of the bony depression, and the depressed bone removed 
and also the usual area of the squamous bone rongeured away; the 
underlying dura was thickened, especially beneath the depressed 
bone, and it bulged outward under high tension upon removing the bone. 
Upon opening the dura, which was very much thickened, the cere- 
brospinal fluid spurted to the height of 2 inches and, upon en- 
larging the dural opening, the underlying "wet" edematous cortex 
tended to protrude but did not rupture, owing to the rapid escape of much 
cerebrospinal fluid. No subdural hemorrhagic cyst observed, but along the 
cortical vessels in the sulci was a hazy whitish thickening — undoubtedly due 
to a former supracortical hemorrhage. The cerebral cortex beneath the 
depressed area of the vault was in no way more damaged than the adjacent 
areas as described above. Xo signs of cortical laceration or cortical hemor- 
rhage observed. Normal pulsation at end of operation. Usual closure with 
2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes — Uneventful convalescence in that operative incision 
healed per primam; it was observed on the fourth day after operation that 
the right arm and right leg were definitely less stiff and less spastic than 
before the operation and the child could move them much more freely and 
less awkwardly ; this improvement rapidly continued. 

Examination at discharge (10 days after operation). — Temperature, 
98.6° ; pulse, 84 ; respiration, 24 ; blood-pressure. 108. No complaints except 
for soreness at site of operation. Decompression area bulges slightly beyond 
the flush of scalp ; normal pulsation. Child walks with a much less limp 
than before the operation, the heel touches the floor and the leg is no longer 
dragged ; the flexor contraction of the right arm is not so marked ; he is able 
to use the hand much more freely than formerly. Pupils equal and react to 
light normally. Reflexes: patellar, right more active than left: right ex- 
haustible ankle clonus and right Babinski still persist ; abdominal reflexes — 
right less active than left. Fundi : retinal veins enlarged ; lower nasal mar- 
gins of both optic disks slightly blurred by edema. 



OCCURRING AT THE TIME OF BIRTH 66 1 

Treatment. — The usual hygienic measures advised, including a thor- 
ough daily massage of the right side of body. 

Examination (May 6, 1914 — 21 days after operation). — No complaints. 
Operative area is flush with the surrounding scalp ; pulsates normally. 
Child can now walk with no limp at all, although rather awkwardly ; right 
arm and right hand are now held down at the side in a much more normal 
position; child is using the hand much more naturally. Reflexes: patellar, 
right more active than left ; no ankle clonus and no Babinski can be elicited ; 
abdominal reflexes, right still slightly depressed. Fundi : retinal veins 
slightly enlarged ; nasal margins are now clear and distinct. 

Examination (June 9, 1914 — 54 days after operation). — No complaints. 
Decompression area possibly slightly depressed beneath flush of scalp ; nor- 
mal pulsation. Complete recovery of the use of right arm and right leg ; no 
noticeable stiffness and spasticity of the right arm and right leg ; child walks 
with no limp and can run in a normal manner; he is now using the right 
hand almost as freely as the left, although the child was formerly considered 
as being left-handed. Parents have noticed a definite mental and emotional 
change in that the child is brighter and is less irritable. Reflexes : patellar, 
right more active than left; no ankle clonus nor Babinski; abdominal re- 
flexes — right' slightly depressed. Fundi : retinal veins possibly larger than 
normal; all details of both optic disks clear and distinct; both optic disks 
slightly paler than normal. 

During the last 5 years, this child has been repeatedly examined and 
the result has been a most gratifying and satisfactory one ; no convulsive 
seizures have occurred, and the physical, mental and emotional condition of 
the child may be considered that of a normal child. (Fig. 199 pictures child 
at five years of age and 3 years after operation. ) At the last examination, on 
April 6, 1919 — 60 months after operation, the operative area was depressed 
and very much narrowed, due to new bone formation about the periphery 
so that it was difficult to perceive any pulsation. The reflexes were active 
but equal and otherwise negative, and, the fundi were negative except for a 
slight pallor of the temporal margins of both optic disks. The mental and 
emotional reactions were normal. 

Remarks. — The condition of this child was one of typical spastic hemi- 
plegia so frequently observed following an intracranial hemorrhage at the 
time of birth and without the complication of a depressed fracture of the 
overlying vault ; it was, however, this bony depression which made the diag- 
nosis such a simple one clinically and there could be no doubt that the 
depressed area of bone overlying the left cerebral motor cortex was the 
cause for the motor impairment of the right side of the body; in the vast 
majority of the patients, however, having a spastic paralysis and due to a 
supracortical hemorrhage at the time of birth, there is no overlying de- 
pressed fracture of the vault, but that does not mean that there cannot be 
a definite cerebral compression due to a supracortical hemorrhage and 
without the complication of a depressed fracture of the vault : these are the 
patients having no depressed fracture of the vault which have been so 
overlooked in the past, and yet the diagnostic signs of the condition are now 
so easily obtained by means of the ophthalmoscopic examination of the fundi 



662 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



i 



> J 





N 



J-*- 



Fig. 199. — The patient at five years of age and three years after the operation of left subtemporal de- 
compression and drainage for the condition of a supracortical hemorrhage at birth associated with a 
depressed fracture of the left parieto-squamous area; the resulting right spastic hemiplegia has disappeared 
while the convulsive seizures have not returned since the operation. 



OCCURRING AT THE TIME OF BIRTH 663 

and the registration of the pressure of the cerebrospinal fluid by means of the 
spinal mercurial manometer and thus the patients having an increased intra- 
cranial pressure can easily be differentiated from those other patients having 
no increased intracranial pressure and naturally not to be benefited by any 
operative procedure upon the skull. The depressed fracture of the vault of 
this patient merely facilitated the diagnosis from a superficial standpoint, 
and yet in this patient there were the definite signs of an increased intra- 
cranial pressure and of such a, height that it was considered advisable to 
open the dura and to let it remain open rather than the mere elevation or 
removal of the bony depression. 

The operative findings of organization of the former supracortical 
hemorrhage in the sulci about the cortical vessels confirmed the opinion of a 
former subdural hemorrhage, and it is this partial blockage of the stomata 
of exit of the cerebrospinal fluid into the cortical veins that produces the 
"wet" edematous condition of the cortex and permits the persistence of an 
increased intracranial pressure in the form of a mild external hydrocephalus, 
which is the secondary pathology in many of these patients. 

The almost immediate and excellent improvement obtained in this 
patient is not an unusual one ; the ultimate result — ten, fifteen and twenty 
years from now, however — may not be that of an entirely normal individual 
— especially in his emotional reactions ; and then again, the great danger of 
epileptiform seizures occurring later in life and due to the irritative presence 
of the residue of the former supracortical hemorrhage in the sulci and about 
the cortical vessels ; the operative drainage of this mild condition of external 
hydrocephalus undoubtedly lessens the irritative effect of the condition, and 
it is hoped entirely so ; a longer period of time, however, must elapse before 
it is possible to state a final opinion. 

As in the other patients having an intracranial hemorrhage at the time 
of birth and usually following a difficult labor with and without the use of 
instruments, the ideal time for the drainage of the supracortical blood and 
the relief of the increased intracranial pressure is as soon as possible after 
the birth — upon the first day, second day, third day and as early as pos- 
sible, when the blood itself can be drained in fluid form, and just as in this 
patient an earlier operation would have afforded not only a greater chance 
of immediate relief and of ultimate complete recovery, but it would have 
avoided the temporary paralysis and the mental and emotional retardation 
which had occurred during the time preceding the operation. The operative 
indication in this particular patient was so self-evident from even a manual 
examination of the skull that it may be considered one of the neg- 
lected patients. 

Case 177. — Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage, a right hemiplegia and an occasional Jacksonian convul- 
sion of the right arm and right leg ; an increased intracranial pressure. Left 
subtemporal decompression and drainage. Marked improvement. 

No. 329. — Frances. Two years. White. IT. S. 

Admitted September 15, 1915 — 24 months after birth and injury. Poly- 
clinic Hospital. Referred by Doctor M. Allen Starr. 



664 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Operation September 22, 1915 — 7 days after admission. Left subtem- 
poral decompression and drainage. 

Discharged October 2, 1915 — 10 days after operation. 

Family history negative. Parents and their relatives all right-handed. 

Personal History. — First child, full term, apparently normal labor and 
no instruments required ; weight, seven and a half pounds at birth ; rather 
difficult to resuscitate, but not more so than in many babies; no convulsive 
seizures or twitchings. The child was considered a normal one until 8 months 
of age, when it was observed for the first time that the right arm and right 
leg were slightly more stiff than the left arm and left leg ; also the child was 
not holding its head up as early as it should; it was at this time, that 
momentary twitchings of the right arm were first observed — not more than 
two or three a week and lasting for only several seconds ; no loss of conscious- 
ness, although mother states that sometimes child ' ' seemed to stare, ' ' while 
the twitching of the fingers of right hand continued. The general condition, 
however, gradually improved so that the child was able to sit up at fourteen 
months of age and began walking at nineteen months of age (5 months 
ago). Speech has been retarded^ so that at present the child is only able to 
say "mamma" and "no." Patient has had daily massage and exercises 
for several months. During the past 6 months, a slight convulsive twitching 
of the right arm and frequently of the. right leg occurred for a period of 
5 to 6 seconds, and it has been observed that while the twitching continued 
the child would have a very "vacant" expression, but no complete loss of 
consciousness. Persistent constipation requiring medicines and enemata. 
No history of injury to the head ; always well and strong. 

Examination upon admission (24 months after birth and injury). — 
Temperature, 98.6°; pulse, 80; respiration, 26. Well-developed and nour- 
ished. Definite spastic paralysis of the right arm and of the right leg, also 
right facial weakness of the cortical type ; no impairment of sensation can 
be elicited. Child holds right arm in the slightly flexed and pronated 
manner typical of spastic paralysis; right leg is slightly flexed at the knee 
and the child walks chiefly upon the toes of the right foot — a mild talipes 
equinus. Mental condition rather retarded — the Simon-Binet test register- 
ing her age as less than two years. Is able to say ' ' mamma, " " no " " Fran " 
and "I," but with indistinctness. No marked impairment of swallowing. 
Pupils equal and react to light normally. Reflexes: patellar exaggerated, 
right more than left ; no ankle clonus but right Babinski ; abdominal reflexes 
— right depressed; reflexes of right arm increased. Fundi — retinal veins 
slightly enlarged ; nasal margins of both optic disks blurred by edema. Lum- 
bar puncture — clear cerebrospinal fluid under increased pressure (approxi- 
mately 14 mm.) ; Wassermann test negative and cell count was 5 cells per 
c.mm. X-ray (Doctor A. J. Quimby) — "no abnormalities observed." 

Treatment. — The presence of an increased intracranial pressure asso- 
ciated with a right spastic hemiplegia and with the history of convulsive 
twitchings of the right arm and at times of the right leg, indicated the 
advisability of a left subtemporal decompression in the belief that a lowering 
of the general intracranial pressure would permit a definite lessening of the 



OCCURRING AT THE TIME OF BIRTH 665 

spasticity and an improvement of the mentality and also afford the patient 
a chance of avoiding the great danger of future epilepsy. 

Operation (24 months after birth and injury). — Left subtemporal de- 
compression and drainage: usual vertical incision, bone removed, and no 
complications; the bone was unusually thin, almost like tissue paper, and 
most probably due to the prolonged increase of the intracranial pressure. 
Dura whitish, thickened and under tension ; upon incising it, clear cerebro- 
spinal fluid spurted to a height of 2 cm. and upon enlarging the dural open- 
ing a very edematous tense cortex protruded but did not rupture. Along 
the vessels in the sulci was a whitish, cloudy, connective-tissue formation — 
the organization of a former subarachnoid and supracortical layer of hemor- 
rhage. The convolutions themselves appeared normal, although possibly 
paler than usual. At the end of the operation, the cortex became more 
relaxed and pulsated almost normally following the loss of much cerebro- 
spinal fluid. Usual closure with 2 drains of rubber tissue inserted. Dura- 
tion, 35 minutes. 

Post-operative Notes. — Uneventful recovery; operative incision healed 
per primam. Decompression area bulged beyond the flush of scalp at the 
time of the patient's discharge — 10 days after operation. 

Treatment. — The usual massage and exercises advised just as before 
the operation. 

Examination (May 20, 1916 — 8 months after operation). — Child has 
made a marked improvement since the operation in that the stiffness of the 
right arm and of the right leg has markedly lessened, the child now using v 
the arm more freely and holding it more naturally, and she is able now to 
walk more upon the right heel rather than upon the toes of the right foot. 
The mentality has very much improved in that she is more alert and is more 
interested in things : she is now able to say a number of sentences and with 
distinctness ; she has not had a convulsive twitching since the operation. De- 
compression area slightly depressed beneath the flush of scalp ; pulsates nor- 
mally ; bony opening somewhat narrower, due to new bone formation about 
the periphery. Patient walks with only a slight limp upon the right foot — 
hardly noticeable. Reflexes — patellar active, right more than left ; no ankle 
clonus but right Babinski still persists ; abdominal reflexes — right less active 
than left ; reflexes of right arm more active than of the left arm. Fundi — 
retinal veins of normal size; details of both optic disks clear although a 
small amount of new tissue formation is present at the lower nasal margins 
of both optic disks. Massage and exercises continued as before. 

Last Examination (April 16, 1919 — 43 months after operation). — The 
condition of the child has continued to improve, and if it were not for the 
very slight awkwardness of the right arm and of the right leg, she might bo 
considered a normal child in every way; mentality excellent and no retarda- 
tion or impairment elicited. . Decompression area is depressed below the 
flush of scalp; normal pulsation palpable. Reflexes: patellar — right greater 
than left; right Babinski persists; abdominal reflexes — right possibly 
less than left; reflexes of right arm more active than those of left. Fundi — 
negative, except for new tissue formation along the lower portions of the 
nasal margins of both optic disks. Child walks, runs and plays with little 



666 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

or no impairment of the right side of the body with the exception of a slight 
awkwardness in the use of the right hand, and its impairment is only elicited 
by special tests. 

Treatment. — The daily massage and exercises are to be continued 
as before. 

Remarks. — It is the marked improvement occurring in patients as in 
this child which impresses one with the advisability of performing the opera- 
tion in these selected children having an increased intracranial pressure 
due to a hemorrhage at the time of birth — aud as soon as possible after the 
birth and the injury; if such a marked improvement can be obtained two 
years after the injury, surely a greater improvement and even the avoid- 
ance of the results of the intracranial hemorrhage and its increased intra- 
cranial pressure in the later spasticity and mental retardation would have 
been obtained, if the operation had been performed within several days 
after the birth of the child when the drainage of the blood itself would 
then have been possible. Later, and surely after one year of age, all that 
the operation can accomplish is to lower the increased intracranial pressure 
both by offsetting the pressure effects of the hemorrhage and its resulting 
cystic and fibrous tissue formation and, more important, to afford drain- 
age to the partially blocked cerebrospinal fluid as a result of the hemor- 
rhage in the sulci forming connective tissue organization about the cortical 
veins and in this manner the condition of mild external hydrocephalus is 
developed. Naturally, the ideal treatment of these selected patients is the 
drainage of the blood itself within a few days after the birth of the child 
and the improvement to be obtained in these older patients merely empha- 
sizes the necessity of more careful examinations and more accurate diagnosis 
at the time of the birth of the patient — rather than months and even 
years later, when the spasticity and mental impairment are well developed 
and when the probability of obtaining a normal child is practically nil and 
all that can be expected even with the most successful of cases is merely an 
improvement and an approximation to normality. In all newborn babies, 
whether the labor is apparently a normal one or whether it is a difficult 
one with and without the use of instruments, if the child does not appear 
to behave as it normally should by being rather drowsy or stuporous and 
surely in the presence of convulsive twitchings, or if it should be a "blue" 
baby, then careful ophthalmoscopic examinations should be made and 
repeated lumbar punctures, if necessary, to determine the pressure of the 
cerebrospinal" fluid and the presence or not of blood in it ; it is only by this 
means that a large number of babies having an intracranial hemorrhage 
at the time of birth will be diagnosed early and the appropriate treatment of 
spinal drainage or the cranial decompression and drainage instituted early. 

Although the improvement in this patient has been excellent and the 
cessation of the convulsive twitchings most hopeful, yet it will be necessary 
for a period of years to elapse before it can be definitely stated that the 
child is beyond the risk of epilepsy ; it will also be necessary to wait until 
this child enters into active life with its strain and stress before it can be 
definitely ascertained, whether its reactions are as normal as they should be ; 






OCCURRING AT THE TIME OF BIRTH 667 

in fact, it would be better judgment that this child should be restricted in 
its life and not be permitted to lead a too strenuous existence, filled with 
excitement and unnecessary cares and worries. 

Case 178. — Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage and a resulting" spastic diplegia; an increased intra- 
cranial pressure. Right subtemporal decompression. Marked improvement. 

No. 1005.— Ruth. Two and a half years. White. U. S. 

Admitted July 14, 1917 — 30 months after birth and injury. Polyclinic 
Hospital. Referred by Doctor B. H. Whitbeck. 

Operation July 19, 1917. Right subtemporal decompression and 
drainage. 

Discharged July 30, 1917 — 11 days after operation. 

Family history negative ; two older children living and well. 

Personal History. — Third child, full term, face presentation, difficult 
labor requiring instruments; rather bluish at birth, requiring prolonged 
efforts to resuscitate her; no convulsive twitchings. Apparently a normal 
child and was so considered until 12 months of age, when it was realized 
that the child was not holding her head up as well as normally and could 
not sit up alone. At sixteen months of age, it was observed for the first time 
that both legs were rather stiff and adducted and that the thighs could not 
be adducted unless with effort ; also that the left foot • ' turned in. ' ' Vigorous 
daily massage and passive exercises were administered and at the eighteenth 
month the child succeeded in sitting up alone. The physical development 
was slow and although the child was well-nourished and apparently well- 
developed, yet she has never been able to walk and does not attempt to 
crawl about like other children. Mentality only slightly impaired. No 
convulsive seizures. Patient has received daily massage during the past 
18 months, but with little or no improvement. 

Examination upon admission (30 months after birth and injury). — Tem- 
perature, 98.6°; pulse, 82; respiration, 26. Well-nourished child. Unable 
to walk due to the stiffness of both legs which are held slightly flexed and 
adducted — "scissors" type; when held up, patient stands upon the toes. 
Arms slightly stiff but much less so than the legs. Mentality only slightly 
impaired — Simon-Binet tests registering her age as of 2 years. No history 
of convulsive seizures or twitchings. Patient can sit up alone but with 
some difficulty. Pupils equal and react normally. No nystagmus. Reflexes : 
all exaggerated ; patellar very active, left more than right ; no ankle clonus 
but double Babinski ; abdominal reflexes present but depressed equally ; both 
arm reflexes slightly increased. Fundi — retinal veins slightly enlarged with 
thickened walls; nasal margins of both optic disks blurred by edema and 
physiological cups are both shallow from new tissue formation ; both optic 
disks are possibly paler than normally. Lumbar puncture — clear cerebro- 
spinal fluid under increased pressure (16 mm.) ; Wassermann test nega- 
tive and cell count was 3 cells per c.mm. X-ray (Doctor W. II. Stewart) 
— "negative." 

Treatment. — The spastic diplegia and slight mental retardation asso- 
ciated with an increased intracranial pressure made it advisable to perform 
a subtemporal decompression in the belief that a lowering of this increased 



668 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

intracranial pressure would permit a definite lessening of the spasticity and 
afford the patient a chance of improvement both physically and mentally; 
the absence of convulsive seizures made the case a more hopeful one from 
the standpont of the ultimate prognosis ; the left side of the body being more 
impaired, a right subtemporal decompression was performed. 

Operation (30 months after birth and injury). — Eight subtemporal 
decompression and drainage : usual vertical incision, bone removed, and no 
complications. Dura whitish, thickened and tense; upon incising it, clear 
cerebrospinal fluid welled out in large quantity, forming a "puddle"; the 
underlying edematous cortex protruded but did not rupture, as the amount 
of the escaping cerebrospinal fluid was profuse. No gross signs of former 
supracortical hemorrhage observed, except along the cortical veins in the 
sulci there was a whitish induration and a sort of cystic formation lying 
upon the cortex and beneath the arachnoid; upon puncturing the latter, 
much straw-colored fluid escaped, permitting the cyst to collapse and the 
underlying cortex to rise. At the end of the operation, the cortex pulsated 
almost normally, but the intradural pressure was still increased. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 30 minutes. 

Post-operative Notes. — Uneventful recovery; wound healed per primam, 
and the area bulged tensely but pulsated. Before the child left the hospital 
at the end of ten days, a definite lessening of the spasticity of both legs 
was observed — and possibly of the left more than of the right leg. 

Treatment. — The parents were advised to continue the daily massage 
and exercises as before the operation. 

Examination (May 10, 1918 — 10 months after operation). — A very 
marked improvement of the condition has occurred since the operation; 
the spasticity of both legs has so lessened that they no longer are adducted 
and the child is able to crawl and is trying to stand alone ; she no longer 
stands upon the toes. Use of both arms has also improved so that they are 
now practically normal. Much brighter mentally and the child is able to talk 
as a normal child. Decompression area remains flush with the surrounding 
scalp ; normal pulsation. Keflexes — patellar active but equal ; no ankle 
clonus but double Babinski persists; abdominal reflexes present and equal; 
reflexes of both arms active but equal. Fundi — retinal veins slightly en- 
larged ; slight blurring of the lower nasal margins of both optic disks. 

Treatment. — The daily massage and exercises to be continued ; it is hoped 
that the decompression area will become depressed beneath the flush of the 
scalp and thus indicate the permanent lessening of the intracranial pressure ; 
if this does not happen within a year, it will probably be necessary to per- 
form a left subtemporal decompression and drainage in order to permit the 
greatest ultimate improvement to occur. (The parents, however, are so 
pleased with the continued improvement of the child that a second operation 
is not desired.) 

Last Examination (June 10, 1919 — 23 months after operation). — The 
marked improvement continues so that now the child is able to walk with 
braces devised by Doctor Whitbeck and in every way it would seem that the 
child is approximating normality, and especially is this true of the men- 
tality. The decompression area is becoming slightly depressed and it is now 



OCCURRING AT THE TIME OF BIRTH 



669 



believed that a bilateral decompression will not be necessary. The use of the 
arms is excellent. Reflexes : increased but equal ; double Babinski still per- 
sists; arm reflexes negative. Fundi — retinal veins possibly slightly enlarged ; 
an indistinct blurring of the lower nasal margins of both optic disks persists : 
the new tissue formation remains as before the operation. The photo- 
graph shows the present improved condition of this patient (Fig. 200). 

Remarks. — The operative findings and the rapid subsequent improvement 
of the condition of this patient are very impressive ; if, at the time of birth 
and when it was observed that the child was cyanotic, requiring vigorous 
resuscitation, a lumbar puncture had been performed disclosing an increased 
pressure of the cerebrospinal fluid and 
the presence of blood — if then there had 
been performed a decompression and 
drainage of the free supracortical blood, 
not only would this physical and mental 
impairment have been avoided but the 
child could have become a normal child. 
If only an increased pressure was ascer- 
tained at the time of birth and little or 
no blood found in the cerebrospinal fluid 
at lumbar puncture, then repeated lum- 
bar punctures might have in themselves 
been sufficient to lessen the intracranial 
pressure by the drainage of the excess 
cerebrospinal fluid and any free blood, 
and in this way a normal child be ob- 
tained without the added risk of a 
cranial operation and drainage. 

It will be necessary to wait in this 
patient for a period of years to elapse 
in order to estimate the ultimate im- 
provement to be obtained, and this is true 
of all these children upon whom the 
cranial operation of decompression and 
drainage has been performed— the first operation being in June, 1913 ; so far. 
the younger the child when operated upon, the greater the improvement. 

Case 179.— Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage and a resulting spastic diplegia, mental retardation 
and convulsive seizures ; an increased intracranial pressure. Left subtem- 
poral decompression. Definite improvement. 

No. 91.— Elsie. Six years. White. U. S. 

Admitted November 15, 1914—6 years after birth and injury. Poly- 
clinic Hospital. Referred by Doctor J. A. Bodine. 

Operation November 24, 1914. Left subtemporal decompression 
and drainage. 

Discharged December 8, 1914—14 days after operation. 

Family history alcoholic; sister of father was epileptic: otherwise nega- 
tive; three older children living and well; no miscarriages for mother. 




Fig. 200. — The present improved condi- 
tion of the patient — an almost normal men- 
tality, and a spasticity of only slight degree. 



670 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Personal History. — Fourth child, full term, normal labor; apparently- 
normal after birth until the third day, when a series of general convulsions 
occurred — ten on the third, six on the fourth day and three on the fifth day 
after birth ; these general convulsive seizures gradually lessened in frequency 
until the third year when a convulsion occurred on the average of one 
each week; after the third year and until admission to the hospital, a 
general convulsive seizure occurred on an average of one each month: no 
localizing signs at any time. General retardation of the physical develop- 
ment of the child in that it could not sit up until sixteen months of age, 
only learned to creep at 2 years of age and was unable to walk until 3 
years of age. The definite stiffness of both legs and more of the right leg 
was not noticed until the child was 12 months of age; this spasticity 
gradually increased in spite of daily massage, so that when the child finally 
learned to walk at 3 years of age it did so with a typically spastic gait — 
the right side of the body being much worse than the left. The child has 
always carried the right arm flexed at the elbow and at the wrist with the 
hand held in the position of pronation. The child finally learned to talk 
in monosyllables at 3 years of age and the speech has gradually improved. 
Definite retardation of mentality, so that it has been impossible to send 
the child to school. Very irritable, having a "bad temper," and she is 
very difficult to manage — especially after the convulsive seizures which 
occur now on an average of one each month. During the past two years, 
the patient has received massage daily and triple bromides. 

Examination upon admission (6 years after birth and injury). — Tem- 
perature, 98.6°; pulse, 84; respiration, 26. Rather poorly developed and 
nourished. A condition of mild spastic diplegia with the right side more 
spastic than the left; both thighs adducted and flexed at the knees, right 
more than left; child walks upon the toes of the right foot in the position 
of talipes ecjuinus ; the right arm is held flexed at the elbow with the wrist 
and the hand pronated — the typical position assumed by patients having 
the condition of spastic paralysis (Fig. 201). The left arm and left leg 
are only slightly spastic and with only mild muscular contractions. Men- 
tality is that of a child of four years; irritable and rather surly. (Last 
convulsive seizure occurred 10 days ago ; it began with a typical epileptic 
cry to be followed by a characteristic general convulsive seizure with no 
localizing signs ; the tonic and clonic muscular contractions lasted for almost 
3 minutes.) Right facial weakness of the cortical type (the upper third 
of right side o± face not being involved). Pupils equal and react to light 
normally. Reflexes: patellar — both exaggerated, right much more than 
left ; right ankle clonus and double Babinski ; reflexes of both arms increased, 
right more than left. Fundi — retinal veins dilated: nasal halves of both 
optic disks obscured by edema ; both physiological cups shallow from edema- 
tous tissue. Lumbar puncture — clear cerebrospinal fluid under increased 
pressure (approximately 18 mm.) ; Wassermann test negative and cell count 
was 4 cells per c.mm. X-ray (Doctor A. J. Quimby) — "no abnormality 
of the skull is observed, except a thinning of the vault posterior to the 



OCCURRING AT THE TIME OF BIRTH 



67: 




Fig. 201. — The patient, six years of age, having a right spastic hemiplegia (affecting chiefly the right 
arm), following a supracortical hemorrhage at the time of birth with resulting mental retardation and 
convulsive seizures. Marked improvement followins a left subtemporal decompression and drainage at 
Bix years of age. 



anterior fontanelle and very probably due to a prolonged increase of the 
intracranial pressure." (Fig. 202.) 

Treatment. — The occurrence of convulsive seizures on the third day after 
an apparently normal birth and the later development of the condition 
of spastic diplegia with mental retardation in the presence of a marked 



672 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

increase of the intracranial pressure — this clinical picture made most prob- 
able the diagnosis of an intracranial hemorrhage at the time of birth and 
the resulting increased intracranial pressure as being due to this former 
hemorrhage with a subsequent partial blockage of the excretion of the 
cerebrospinal fluid — a mild condition of external hydrocephalus. A left 
subtemporal decompression and drainage was advised as a means of lower- 
ing this increased intracranial pressure and thus affording this patient a 
definite chance of improvement. 

Operation (6 years after birth and injury). — Left subtemporal decom- 
pression and drainage : usual vertical incision, bone removed, and no com- 
plications. Dura thickened, whitish and tense ; upon incising it, clear cere- 
brospinal fluid spurted to a height of 2 cm., exposing a very edematous cortex. 

Above the Sylvian fissure 
was an extensive cystic for- 
m a t i o n compressing the 
underlying cerebral convolu- 
/ tions and extending upward 

/ beyond the upper edge of the 

dural opening ; numerous ad- 
hesions between the outer 
wall of this cyst and the over- 
lying dura were present. 
About the vessels in the 
sulci, and especially above 
.^ the Sylvian fissure, was a 

■| cloudy induration — the re- 
|j| suit of a former subarach- 
noid hemorrhage. Much 
cerebrospinal fluid escaped 

Fig. 202.— Pressure atrophy of the inner table of the during the Operation SO that 
vault just posterior to the anterior fontanelle and most prob- f>,p r>PT*pbT»al rml«9"Hrm bp 
ably due to a prolonged increase of the intracranial pressure. Llie Leieuidl puibdliuil Utf 

came normal. Usual clos- 
ure with 2 drains of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery; incision healed 
per primam and at discharge on the fourteenth day after operation, the 
decompression area bulged only slightly beyond the flush of scalp ; no con- 
vulsions occurred during the hospital residence. 

Examination (May 6, 1916 — 18 months after operation). — A definite 
improvement has occurred both mentally and physically in that the left 
side of the body is practically normal, whereas the spasticity and contractures 
of the right arm and of the right leg have so lessened that these extremities 
can be used awkwardly; the mentality has definitely improved but com- 
paratively less than the physical condition. No convulsive seizures, how- 
ever, have occurred since the operation. Less irritable, and mother states 
that the child is now ' ' a pleasure to live with. ' ' Reflexes : patellar — right 
exaggerated; exhaustible right ankle clonus and double Babinski still 
persist ; abdominal reflexes — right possibly less active than left ; deep reflexes 
of right arm increaspd. Fundi — retinal veins slightly enlarged ; no edema- 



OCCURRING AT THE TIME OF BIRTH 673 

tous blurring of the details of either optic disk; connective-tissue forma- 
tion is present as before the operation. Vision apparently 16/20 in each 
eye. Decompression area depressed beneath the flush of the scalp and 
pulsates normally. 

Last Examination (April 22, 1919 — 53 months after operation). — This 
patient has continued to improve so that now there is only a slight limp of 
the right leg and a definite awkwardness and spasticity in the use of the 
right arm ; the mentality has steadily improved, although the mental age is 
registered as being 2 years below normal; no convulsive seizures have 
occurred. Reflexes : patellar — right much greater than left ; no ankle clonus 
but double Babinski; deep reflexes of right arm are more active than of 
left. Fundi — retinal veins of normal size ; all details of both optic disks 
clear and distinct except for a small amount of new tissue formation at the 
margins and in the physiological cups (as at examination before the opera- 
tion). Decompression area remains depressed beneath the flush of scalp 
but pulsates normally; operative opening smaller from new bone forma- 
tion about the periphery. 

Remarks. — The cessation of the convulsive seizures to the extent that not 
one convulsion has occurred since the operation is most impressive regarding 
the apparent beneficial effect of the lowering of the increased intracranial 
pressure — even in the presence of numerous adhesions between the dura and 
the underlying cerebral cortex. Naturally, these adhsions at the operative 
site were severed as far as possible and yet beyond the bony edge of the 
decompression opening, other similar adhesions could be seen extending 
upward, forward and backward and most probably they were present very 
extensively over the cerebral cortex, so that it cannot be advocated that the 
removal of several cortical adhesions was the cause for this marked improve- 
ment and cessation of the epileptiform seizures, but rather this improvement 
is due to the lowering of the increased intracranial pressure alone ; in other 
patients where no cortical adhesions are found, yet the convulsive seizures 
in these patients may cease entirely following a simple decompression. It 
is my belief as a result of observing a number of these similar patients that 
the epileptiform seizures occurring in them are more the result of the 
original brain injury associated with an increased intracranial pressure, and 
that cortical adhesions are only a small factor in the condition. A longer 
period of time must elapse in this patient before it can be stated with any 
degree of certainty that the convulsive seizures will not recur — in fact, if 
there is no recurrence before the patient reaches the age of 30 years, then 
the danger of their reappearance is very slight indeed. 

The persistence of the impairment of the right arm and of the right leg 
is undoubtedly due to a definite damage to the cortical cells underlying the 
cystic formation over the left cerebral hemisphere, and it will be most 
probably a permanent one. Clinically, however, this condition of the 
patient which was at the time of the operation one of spastic diplegia has 
been changed to one of right spastic hemiplegia of mild degree, and it 
was the lessening of the general intracranial pressure by means of the left 
subtemporal decompression that permitted the spasticity of the left arm 
and left leg to disappear — an impairment due most probably to the mild 
43 



674 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

supracortical lesion over the right cerebral hemisphere ; the disappearance 
of the left Babinski is very interesting and instructive. 

Case 180. — Chronic severe brain injury at birth associated with a 
supracortical hemorrhage, causing a left hemiplegia and convulsive seiz- 
ures; an increased intracranial pressure. Right subtemporal decompres- 
sion and drainage. Marked improvement. 

No. 334.— Louise. Twelve years. White. School. U. S. 

Admitted August 18, 1915 — 12 years after birth and injury.- Poly- 
clinic Hospital. Referred by Doctor T. K. Tuthill. 

Operation September 30, 1915. Right subtemporal decompression 
and drainage. 

Discharged October 12, 1915 — 13 days after operation. 

Family history negative; no other children; no miscarriages 
for mother. 

Personal History. — First child, full term, difficult labor, requiring 
instruments ; prolonged efforts to resuscitate the child. It remained drowsy 
and quiet for three days, when a general convulsive seizure occurred to be 
followed by daily convulsions of a general character during the following 
8 days, when they ceased and did not recur until 3 years' ago (when patient 
was 9 years of age). The temperature had not been increased during the 
2 weeks following birth and after the convulsions ceased, the child was 
considered normal in every way until 14 months of age, when it was observed 
that the left leg and left arm were not being used as freely as the right leg 
and right arm, and that there was a definite stiffness of the left leg and 
left arm; this spasticity of the left side gradually increased until at 2 
years of age, there were present the typical flexor contractures and pos- 
tures of the left side of the body. In other ways the development of the 
child was delayed in the holding up of the head, the sitting up and the 
ability of the child to stand and to walk; when the child did finally walk 
at 3 years of age, she dragged the left foot and walked upon her toes; 
the left arm was held in the typical position of spastic hemiplegia — flexed 
at the elbow and at the wrist in pronation. The child was able to talk at 
2 years of age, but she did not develop mentally as rapidly as is normal. 
The usual routine treatment of massage and exercises was administered 
at the Orthopedic Hospital for a period of years and, although the condi- 
tion improved, yet there persisted a definite left spastic hemiplegia with 
mental retardation. Three years ago (when the patient was 9 years of 
age), a general convulsion began in the left arm and then in the left leg 
to be followed by complete loss of consciousness and a tj^pical epileptiform 
convulsive seizure; since that time, these convulsions, usually beginning 
upon the left side and then becoming general, have continued on an aver- 
age of 2 or 3 each week, and the patient has become markedly less alert 
mentally and much more irritable ; the left spastic hemiplegia has remained 
practically the same during the past 6 years. She is referred for treat- 
ment of the convulsive seizures. 

Exammation upon admission (12 years after birth and injury). — Tem- 
perature, 98.6°; pulse, 78; respiration, 24; blood-pressure, 116. "Well- 
nourished girl having a definite left spastic hemiplegia (Fig. 203), and a 






OCCURRING AT THE TIME OF BIRTH 



67 



retarded mentality; little or no interest in her surroundings and rather 
childish; she stands upon the toes of the left foot, owing to the contracture 
of the Achilles tendon (really an anatomical shortening of it due to its pro- 
longed contraction), and the left knee is slightly flexed; the left arm is 
flexed chiefly at the elbow while the hand is held in a mild position of 
pronation; left facial weakness of the cortical type (left forehead muscles 
not involved). Simon-Binet test of mentality indicates her mental age as 
being 8 years. Slight compensatory dorso-lumbar 
scoliosis. Hearing negative; otoscopic examination 
negative. Pupils equal and react normally. Reflexes : 
patellar — left greatly exaggerated ; left patellar and 
left ankle clonus — the latter being restricted by the 
Achilles contracture; left Babinski and no right 
plantar flexion; abdominal reflexes — left absent; 
deep reflexes of left arm exaggerated. Fundi — - 
retinal veins very much enlarged — right possibly 
more than left; definite blurring of the nasal mar- 
gins of both optic disks — possibly more extensive 
over right disk ; newly-formed connective tissue about 
the margins of both disks and in their physiological 
cups, so that they are slightly paler than normally — 
a mild condition of secondary optic atrophy. Vision 
— 16/20 in both eyes. Lumbar puncture — clear cere- 
brospinal fluid under increased pressure (approxi- 
mately 20 mm.) ; Wassermann test negative and cell 
count was 2 cells per c.mm. X-ray (Doctor A. J. 
Quimby) — ' ' convolutional markings of the inner 
table of the vault, especially in the frontal and 
occipital areas and typical of an increased intra- 
cranial pressure" (see Fig. 205). 

Treatment. — In spite of the advanced age of this 
patient, yet the presence of a marked increase of the 
intracranial pressure and the definite localizing signs 
of a left hemiplegia and the history of the convulsive 
seizures frequently beginning in the left arm and 
left leg — these facts made the operation of right sub- 
temporal decompression and drainage advisable in 
the hope that a definite improvement of the physical 
and mental condition could be obtained, and most important of all, a 
lessening of the convulsive seizures. In order to ascertain whether this in- 
creased intracranial pressure was the result of the convulsive seizures 
or whether the increased pressure was possibly a factor in producing the 
convulsive seizures by increasing the cortical irritability, large doses of 
triple bromides were administered so that the patient did not have a con- 
vulsive seizure during a period of 6 weeks, and yet at the end of this 
period the increased intracranial pressure registered a height of approxi- 
mately 20 mm. — that is, just the same pressure as when the convulsive 




Fig. 203.— Left spastic 
hemiplegia in a child 12 years 
of age following a supracorti- 
cal hemorrhage at the time 
of difficult birth. Marked 
improvement following the 
lowering of the increased in- 
tracranial pressure by means 
of a right subtemporal de- 
compression and drainage 
even at this late age. 



676 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

seizures were occurring 011 an average of two or three each week. It was 
then decided that this increased intracranial pressure was a very probable 
factor in producing the convulsive seizures and therefore the operation 
of right subtemporal decompression and drainage was advised. 

Operation (12 years after birth and injury). — Right subtemporal de- 
compression and drainage : usual vertical incision, bone removed, and no 
complications; much pressure atrophy of the bone, so that it was very 
thin. Dura thickened, whitish and tense; upon incising it, clear cerebro- 
spinal fluid spurted to a height of 6 inches, revealing a very edematous 
cortex which protruded and almost ruptured; warm saline cotton com- 
presses held over the opening until sufficient cerebrospinal fluid had 
drained to permit the cortex to relax and to bulge less tensely. Above 
the Sylvian fissure was a dark; cystic formation lying upon the cortex and 
having a thickness of one-half inch; it was compressing the underlying 
cortical cells, and upon puncturing it, a straw-colored fluid escaped, per- 
mitting the underlying cortex to rise slightly. The vessels in the sulci, 
both above and below the Sylvian fissure, were surrounded by a cloudy 
induration of connective tissue due to the organization of a former sub- 
arachnoid hemorrhage. At the end of the operation, the cortex pulsated 
almost normally. Usual closure with two drains of rubber tissue inserted. 
While the incision was being sutured, a lengthening of the left Achilles 
tendon was performed and, in this manner, the period of anesthesia was 
not prolonged. Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery, so that the patient 
was discharged on the thirteenth day after operation; the decompression 
area bulged rather tensely, but slight pulsation was palpable ; even at this 
early date, there seemed to be a definite lessening of the spasticity of the 
left arm and of the left leg; no convulsive seizures since the operation. 
Parents were advised to continue the massage and exercises of the left arm 
and left leg just as during the 3 years before the operation. 

Examination (May 17, 1917 — 21 months after operation). — A marked 
improvement of the condition of this patient has steadily occurred since 
the operation, in that the left spastic hemiplegia has so lessened that the 
patient can walk with scarcely any limp of the left leg and she can use 
the left arm with much freedom and with only slight awkwardness — espe- 
cially for the finer use of the fingers; the mentality has greatly improved, 
so "that her school reports are much better than formerly and she has 
advanced one year in her classes ; the convulsive seizures have lessened both 
in frequency and in severity — the first convulsion occurring 6 weeks after 
the operation and of comparatively slight character, and these modified 
spells have occurred on the average of only one every six or seven weeks ; 
emotionally, the patient is much better in that she is less irritable and 
according to the mother "is a changed girl." The decompression area is 
slightly depressed beneath the flush of the scalp and pulsates normally; 
some new bone formation about the periphery has narrowed the opening 
slightly. Pupils equal and react normally. Reflexes: patellar — left very 
active; exhaustible left ankle clonus and left Babinski; abdominal reflexes 
— left depressed ; deep reflexes of left arm more active than right. Fundi — 



OCCURRING AT THE TIME OF BIRTH 677 

retinal veins slightly enlarged; no edematous blurring of the details of 
either optic disk but their new tissue formation and pallor still persist. 
Vision 16/20 in each eye. 

Last Examination (July 16, 1919 — 47 months after operation). — The 
marked improvement of this patient has continued in that there is now only 
a very slight impairment of the left arm and leg, the mentality is becoming 
more and more normal in that the Simon-Binet tests register an age of 15 
years and the convulsive seizures do not occur more frequently than once 
every two or three months. The decompression area is depressed beneath the 
flush of the scalp and pulsates normally. Reflexes : patellar — left more active 
than right ; no ankle clonus but left Babinski persists ; left abdominal reflexes 
depressed; reflexes of left arm more active than of right arm. Fundi — 
retinal veins possibly enlarged ; no blurring of the margins of the optic disks 
disclosed. Vision still remains 16/20 in each eye. 

Remarks. — The continuance of the convulsive seizures even in a less 
severe form and of less frequent occurrence makes the prognosis of this 
patient a most doubtful one ultimately and it would be most surprising if 
the epilepsy should entirely disappear ; this is the type of patient and condi- 
tion in whom a good result might possibly have been obtained, if the 
operative relief of the increased intracranial pressure could have been 
performed earlier — if not within several days after birth, then surely within 
the first two or three years of life. The end result of this patient will be 
reported later in detail. 

It is most important in patients having convulsive seizures and there is 
present a definite increase of the intracranial pressure to ascertain accu- 
rately whether this increased intracranial pressure is a secondary one due 
to the cerebral edema which results from frequent convulsive seizures — the 
typical "wet brain" of epileptics, or whether the increased intracranial 
pressure is a possible factor in increasing the cortical irritability and there- 
fore a primary rather than a secondary sign of the convulsions ; it is only 
in these selected patients that the relief of the increased intracranial pres- 
sure affords a definite chance of improvement. An excellent method to ascer- 
tain whether the increased intracranial pressure is a primary rather than 
a secondary one following the convulsions is to saturate the patient with 
triple bromides or luminal sufficiently so that no convulsive seizures occur 
for a period of at least 4 weeks, and better, 6 weeks; if at the end of this 
period of freedom from convulsions, the pressure of the cerebrospinal fluid 
as registered by the spinal manometer is normal or only slightly above nor- 
mal, whereas before this period of freedom from convulsions, the pressure 
was registered as being definitely increased (above 15 mm.), then it is known 
that the increased intracranial pressure is due to the convulsions them- 
selves and results from the cerebral edema secondary to the convulsive seiz- 
ures; whereas, if the pressure of the cerebrospinal fluid remains the same 
after the period of freedom from attacks just as before this period, then it 
is known that the increased intracranial pressure is a primary rather than a 
secondary factor and that a lowering of this increased intracranial pressure 
by means of a subtemporal decompression and drainage might afford the 
patient a definite chance of improvement by lowering the cortical irritabil- 



678 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

ity. This method of differentiating patients having convulsive seizures has 
been used in a large number of patients during the past two years and it 













Fig. 204. — Severe condition of spastic diplegia with mental retardation in a child of 4 years of age 
following a supracortical and cortical hemorrhage at the time of instrumental delivery. Marked improve- 
ment following a lowering of the increased intracranial pressure by means of a left subtemporal decompression 
and drainage. 

has been most satisfactory; naturally, patients having convulsive seizures 
must be given most doubtful prognoses — no matter what the treatment, and 
especially if the condition has persisted for a period of years, so that the 



OCCURRING AT THE TIME OF BIRTH 679 

cerebral cortex has reached a degree of irritability which no treatment of any 
kind can permanently alter — the so-called epileptic habit. It is only in 
the very early conditions that it is possible to offer the patient a chance of 
recovery — and usually it is only a temporary improvement, if any at all. 

Case 181. — Chronic severe brain injury associated with cortical and 
supraoortical hemorrhages and a resulting" spastic diplegia and retarded 
mentality; a marked increase of the intracranial pressure. Left subtem- 
poral decompression. Marked improvement. 

No. 296.— Marjorie. Four years. White. U. S. 

Admitted June 1, 1916 — 4 years after birth and injury. Polyclinic Hos- 
pital. Referred by Doctor John A. Wyeth. 

Operation June 7, 1916. Left subtemporal decompression and drainage. 

Discharged April 16, 1916 — 9 days after operation. 

Family history negative ; no other children ; no miscarriages. Parents 
and relatives are all right-handed. 

Personal History. — First child, full term, head presentation, instrumen- 
tal delivery; ten minutes required to resuscitate the child; weight, ten 
pounds ; no convulsions. Chdd was considered a normal child until 6 months 
of age, when it was noticed that the right side of the body was slightly stiff 
and was not being moved as freely as the left side ; child not holding its head 
up as early as it should normally. At 8 months of age, it was noticed 
that both legs were slightly stiff and spastic and there was a tendency to 
adduct the thighs — the right more than the left ; it was also definitely ascer- 
tained that the right arm could not be moved as freely as the left arm. At 
2 years of age, the child had, improved sufficiently to be able to sit alone 
but was unable to stand alone ; both legs were distinctly spastic with marked 
adduction; the speech was also retarded in that the child could say only 
"mamma," "papa" and several other short words. No convulsions at any 
time. The patient has received daily massage ever since the age of 6 months. 

Examination upon admission (48 months after birth and cranial injury) . 
— Temperature, 98.6° ; pulse, 86 ; respiration, 26. Rather well-developed and 
nourished child. Head of normal size and shape. Mentality retarded in 
that child was not interested in its surroundings and less alert than nor- 
mally; she says several short words but no sentences. Child cannot stand 
alone. (Fig. 204.) Both legs stiff with moderate flexion and adduction at 
knees; tendency to stand upon the toes of each foot — right more than left, 
due to mild Achilles contracture. Right arm slightly impaired in that the use 
of it was more awkward than of the left arm. Hearing negative (wateh 
test). Pupils equal and react normally. Reflexes — patellar exaggerated. 
right more than left; right ankle clonus and double Babinski, Oppenheim 
and Gordon reflexes more marked on the right side ; abdominal reflexes de- 
pressed; deep reflexes of the right arm slightly increased. Fundi — retinal 
veins enlarged ; nasal margins of both optic disks blurred by edema ; no 
obscuration of the other details of either optic disk. Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (approximately IS mm.) : 
Wassermann test negative and cell count 3 cells per e.inm. X-ray ( Doctor 
A. J. Quimby) — "eonvolutional markings of the entire vault and indicating 
an increase of the intracranial pressure" (Fig. 205V 



68o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



Treatment. — In the belief that a lowering of this increased intracranial 
pressure by means of a subtemporal decompression, and if necessary, a bilat- 
eral decompression would afford this patient a lessening of the spasticity and 
a chance for a definite mental improvement so that the ultimate result 
would not be a hopeless condition, it was decided to perform a left sub- 
temporal decompression as the right leg and the right arm were more 
impaired than the left arm and the left leg. 

Operation (48 months after birth and injury). — Left subtemporal de- 
compression: usual vertical incision, bone removed, and no complications. 
Dura whitish, thickened and tense; upon incising it, clear cerebrospinal 
fluid welled out, revealing a very "wet," edematous cortex which bulged 
and tended to protrude but 
did not rupture. Beneath 
the fissure of Sylvius, the 
cortex was negative except 
for the edema and a slight 
cloudy induration about the 
vessels in the sulci, but above 
the Sylvian fissure there was 
a bluish cystic formation 
lying in the cortex itself and 
extending upward beyond 
the bony margin of the de- 
compression opening; it was 
almost 4 cm. in width. Upon 
incising its outer wall, a 
small amount of straw-col- 
ored fluid escaped, permit- 
ting the walls of the cyst to 
collapse and the underlying 
cortex to rise slightly, 
although it was very much 
atrophied. The surrounding 
cortex was negative except 
for the edema and the whitish cloudiness about the vessels in the sulci (the 
residue from the absorption of a former subarachnoid hemorrhage). As 
a profuse escape of cerebrospinal fluid had occurred, together with the 
evacuation of the cortical cyst, the cortex became less tense, and at the end 
of the operation it pulsated normally. Usual closure with 2 drains of rubber 
tissue inserted. Duration, 40 minutes. 

Pod-operative Notes. — Uneventful recovery ; incision healed per primam; 
at discharge, the operative area bulged slightly beyond the flush of scalp but 
pulsated normally. 

Examination (May 20, 1917 — 11 months after operation). — A very 
marked improvement of both the spasticity and mentality has occurred; 
although the right arm and the right leg are still slightly stiffer than on the 
left side, yet the child is now able to walk with difficulty and the stiffness 
is very markedly lessened ; mentally, the child is much brighter and is speak- 




Fig. 205. — Lateral rontgenogram of a four year old 
child having the condition of spastic diplegia due to a supra- 
cortical hemorrhage at birth. The convolutional markings of 
pressure atrophy of the inner table of the vault indicate the 
prolonged increase of the intracranial pressure which was con- 
firmed by the special tests. 



OCCURRING AT THE TIME OF BIRTH 681 

ing in sentences. No convulsive seizures have occurred. Decompression 
area is slightly depressed beneath the flush of scalp. Reflexes — patellar 
active, right more than left ; no ankle clonus and a left Babinski cannot be 
obtained, while a right Babinski only with difficulty and no Oppenheim or 
Gordon reflexes ; deep reflexes of right arm possibly more active than of left. 
Fundi — retinal veins possibly enlarged ; no edematous blurring of the nasal 
margins of either optic disk. 

Last Examination (April 4, 1919 — 34 months after operation). — This 
patient has continued to improve so that she is able to walk and to run with 
only a slight spasticity of the right leg and an awkwardness in the use of the 
right arm. The mentality has so improved that the Simon-Binet tests would 
indicate the child as being of five years rather than six years of age. No 
convulsive seizures have occurred. Decompression area depressed ; its size 
is slightly smaller owing to new bone formation about the periphery ; pulsa- 
tion normal. Reflexes — patellar, increased, right more than left ; no ankle 
clonus but right Babinski still persists ; deep reflexes of right arm possibly 
greater than those of left arm. Fundi — retinal veins negative; details of 
both optic disks clear and distinct. Parents were advised to continue massage 
and exercises and to prevent the child from leading a too exciting life at 
school — possibly on half time ; no meats or meat soups, and no tea or coffee ; 
to avoid, if possible, the extreme heat of the summer. 

Remarks. — The marked improvement occurring in this patient, and espe- 
cially following the operative findings of apparently a cortical hemorrhage 
and therefore with a permanent destruction of the affected cortical cells, is 
most gratifying ; undoubtedly, the cortical cells beneath the cystic formation 
were compressed and functionally impaired rather than actually destroyed 
and atrophied, and this would account for the excellent recovery of function 
of the extremities and the lessening of the spasticity ; the persistence, how- 
ever, of a mild impairment of the right leg and less so of the right arm results 
most probably from a permanent damage of a number of the cells and this 
condition will undoubtedly continue. 

The marked improvement of the mentality emphasizes the effect of a 
definite increase of the general intracranial pressure upon the development 
of children and the necessity of the early relief of this increased intracranial 
pressure is urgently indicated ; naturally, the earlier the relief is possible the 
greater the recovery and the more normal the individual — the ideal time for 
the operative procedure being within several days after birth, when the 
hemorrhage itself can be drained and not merely the effects of the former 
hemorrhage as in these chronic patients years later. 

The danger of convulsive seizures occurring in this patient and in others 
similarly affected is a great one and must always be feared ; the chances of 
their occurrence in this patient are much less following the operation than 
if no relief of the increased intracranial pressure had been afforded. 

Case 182. — Chronic severe brain injury at birth associated with a supra- 
cortical and cortical hemorrhage resulting in a left spastic hemiplegia, 
mental retardation and convulsive seizures; an increased intracranial pres- 
sure. Right subtemporal decompression and drainage and one month later. 
a left subtemporal decompression and drainage. Marked improvement. 



682 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

No. 48. — William. Eight years. White. Special school. U. S. 

Admitted January 2, 1914—8 years after birth and injury. Hospital for 
the Ruptured and Crippled. Referred by Doctor Yirgil P. Gibney. 

Operations. — First, January 5, 1914; right subtemporal decompression 
and drainage. Second, January 31, 1914; left subtemporal decompres- 
sion and drainage. 

Discharged February 21, 1914 — 21 days after second operation. 

Family history negative ; two younger children living and well ; no mis- 
carriages for mother. 

Personal History. — First child, full term, difficult labor requiring instru- 
ments; child remained in a . semiconscious condition for one week, but no 
convulsive seizures occurred. Within one month after birth, the baby 
was considered a normal one and it was not until 8 months of age that 
it was observed that the left arm and left leg were slightly stiffer than 
the right arm and right leg; the child, however, was able to hold its head 
up at the normal age, but the time of its sitting up and attempting to walk 
was delayed several months. At 2 years of age, the child was able to walk 
with difficulty by dragging the left leg, which had become markedly spastic, 
adducted at the thigh and with a definite contracture of the left Achilles 
tendon, so that the child walked upon the toes of the left foot; the left 
arm was held flexed at the elbow and at the wrist with the hand pronated. 
The parents were instructed regarding massage and exercises of the left 
arm and left leg and these were administered daily up to the present time. 
At three years of age, the child "fainted" — suddenly stared, and fell from 
his chair, but did not "shake"; during the past live years, these "fainting" 
spells have occurred at irregular intervals of three months on an average 
and on only 6 occasions did the child have a convulsive seizure of the left 
side of the body — the attack always beginning in the left leg. The men- 
tality was definitely impaired, so that the child is now going to a "special" 
school; very irritable — having; "fits of temper." Patient has received 
the usual routine treatment of patients of this character — daily massage, 
exercises, etc. 

Examination upon admission (8 years after birth and injury). — Tem- 
perature, 98.6° ; pulse, 80; respiration, 26. Fairly well nourished. Typical 
condition of left spastic hemiplegia with flexor contractures of the arm and 
leg — the gait being a typical one with a dragging of the left foot and walking 
upon the toes of the) left foot ; left side of face smaller than the right side 
and definitely weak — being of the cortical type of left facial paralysis in that 
the left forehead muscles are not involved. Superficial Simon-Binet tests 
register the mentality as being about 5 years of age ; rather dull and non- 
observant of surroundings; very irritable. Hearing negative; otoscopic 
examination negative. Pupils equal and react to light normally. Reflexes : 
patellar — left very much exaggerated ; left patellar and ankle clonus ; double 
Babinski ; abdominal reflexes depressed but equal ; deep reflexes of left arm 
exaggerated. Fundi — retinal veins dilated ; nasal margins of both optic 
disks blurred by edema; small amount of new tissue formation about the 
margins of both optic disks. Vision could not be accurately estimated owing 
to the lack of concentration of child. Lumbar puncture — clear cerebrospinal 



OCCURRING AT THE TIME OF BIRTH 683 

fluid under increased pressure (approximately 20 mm.) ; Wassermann test 
negative. X-ray negative. 

Treatment. — This marked condition of left spastic hemiplegia with men- 
tal retardation and epileptiform seizures associated with an increased intra- 
cranial pressure was considered as being due most probably to an intracranial 
hemorrhage at the time of the birth of the child, and it was considered 
advisable to lower this increased intracranial pressure even at this late date 
of several years following the original injury ; whether the increased intra- 
cranial pressure was due to hemorrhage or to the condition of external 
hydrocephalus or to some other cause unknown, yet the therapeutic indica- 
tion was to relieve this increased pressure in the hope that the condition 
might then be improved — especially the lessening of the mental impairment 
and of the spastic hemiplegia, and, most important, to afford the patient 
an opportunity of relief from the epileptiform spells; for these reasons, a 
right subtemporal decompression and drainage was performed. 

Operations. — First, right subtemporal decompression and drainage : usual 
vertical incision, bone removed, and no complications; bone itself was 
nnusually thick (almost 1 cm.), very spongy and vascular. (It has been 
ascertained in later patients having this condition of the overlying bone, that 
there is usually a large supracortical or cortical hemorrhagic cyst beneath 
this area of vascular and thickened bone — and it so proved in this patient.) 
Dura whitish, thickened, vascular and under high tension; upon incising 
it, much cerebrospinal fluid escaped, exposing a large supracortical and 
cortical hemorrhagic cyst — bluish in appearance and almost 2 cm. in thick- 
ness, lying almost entirely above the Sylvian fissure and extending upward 
beyond the upper margin of the dural opening; its outer wall was excised, 
allowing more than an ounce of straw-colored fluid to escape, and the 
walls of the cyst then collapsed. The underlying cortex had apparently 
been badly damaged in that it was very much atrophied and anemic ; except 
for the cloudy induration about the vessels in the sulci, the surrounding 
convolutions were normal in appearance but under high tension. At the 
end of the operation, the cortex bulged but pulsated only feebly. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery; the decompres- 
sion area, however, bulged so tensely and remained protruded for a period 
of over 3 weeks following the operation and with such slight pulsation, that 
it was considered wiser to lower this high intracranial pressure still more 
by means of a bilateral subtemporal decompression and drainage which 
was now performed. 

Second Operation (left subtemporal decompression and drainage — 26 
days after first operation). — Usual vertical incision, bone removed, and no 
complications; the bone itself was of normal thickness and character. Dura 
whitish and tense, and upon incising it a small amount of cerebrospinal 
fluid welled out, revealing an edematous cortex; above the Sylvian fissure 
was a supracortical cystic formation resulting from a former subarachnoid 
hemorrhage; the underlying cerebral convolutions were only slightly com- 
pressed and apparently not damaged anatomically. About the vessels in 
the sulci, however, was a small amount of whitish induration but of less 



684 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

extent than over the right cerebral cortex. At the end of the operation the 
cortex receded and pulsated normally. Usual closure with 2 drains of 
rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful operative recovery, the incision healed 
per primam and at the time of discharge, on the twenty-first day after the 
second operation, both decompression areas bulged slightly beyond the flush 
of the scalp but pulsated normally ; even before his discharge from the hos- 
pital, there was a definite lessening of the spasticity of the left arm and of 
the left leg, and it was possible for the patient' to stand upon the left heel 
when pressing down upon the toes ; the left arm was also much more 
"limber. " The parents were advised to continue the massage and exercises 
as before the operations. 

Examination (April 13, 1916 — 27 months after operations) . — A marked 
improvement has steadily progressed during the past 2 years — both mentally 
and physically, and most important of all, there has been no recurrence 
of the epileptiform spells, although he "fainted" twice (the last time, one 
year ago) but he did not "shake." There is still a definite limp of the left 
leg and the left arm is used awkwardly, but he is now able to walk upon the 
left heel and to use his left arm, although not so well as the right arm (Fig. 
206) . The mentality has so improved that he is now able to go to school in a 
regular class but is two grades below the class for his age ; not so irritable 
as formerly and as his father says, ' ' a changed boy in every way. ' ' Reflexes : 
patellar — left more active than right; exhaustible left ankle clonus and 
double Babinski ; reflexes of left arm more active than of right. Fundi — 
retinal veins slightly enlarged ; no edematous blurring of the details of either 
optic disk ; connective-tissue formation persists as before the operation. 
Both decompression areas are depressed and pulsate normally; slightly 
smaller due to new bone formation about the periphery. 

Last Report (Sept. 22, 1919 — 67 months after operations). — Letter from 
father states, "William has steadily improved, and, although he is not yet 
a normal boy, he is developing mentally and physically each year. No 
fit during the past two years." 

Remarks. — The operative findings of not only a supracortical but also a 
cortical hemorrhagic cyst of the right hemisphere indicate that the cortical 
damage over this area is a permanent one and therefore no complete recovery 
of the left arm and left leg is possible ; however, an improvement was 
possible following the puncture of the cyst itself and the lowering of the 
general intracranial pressure owing to the fact that the cortical cells about 
the periphery of the cystic formation were merely compressed and function- 
ally impaired — not destroyed as were probably the cortical cells lying 
directly beneath the cyst. A much greater improvement of the left arm 
and left leg would have been possible if the hemorrhage had been a supra- 
cortical one entirely rather than some of it being in the cortex itself. 

The presence of the bilateral Babinski is explained by the operative 
findings over the left cerebral hemisphere and if the hemorrhage over the 
left cerebral hemisphere had been of larger amount, then undoubtedly the 
condition of this patient would have been one of spastic diplegia clinically, 
rather than that of left hemiplegia alone. 



OCCURRING AT THE TIME OF BIRTH 



68: 



If the intracranial pressure is so high that a unilateral decompression 
and drainage is not sufficient to lower the intracranial pressure so that the 
operative area becomes depressed beneath the flush of the surrounding scalp. 




Fig. 206. — Two years following a lowering of the increased intracranial pressure in a boy of S years 
of age having the condition of left spastic hemiplegia with mental retardation and convulsive seizures; 
marked improvement. 



then a bilateral decompression is always advisable and within a period of 
three months, or at most six months, following the first operation. The 
two operations should rarely be performed at the same time and only when 
the intracranial pressure is so high that the closure of the unilateral decom- 
pression would be a difficult procedure with possible damage to the under- 



686 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

lying cortex, unless a bilateral decompression is immediately performed ; this 
necessity rarely occurs. 

Case 183. — Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage and with a resulting condition of spastic diplegia, mental 
retardation and convulsive seizures; an increased intracranial pressure. 
Bilateral decompression and drainage. Marked improvement. 

No. 14. — George. Ten years. White. U. S. 

Admitted September 22, 1913 — 10 years after birth and injury. Poly- 
clinic Hospital. Referred by Doctor John A. Wyeth. 

Operations. — First, October 3, 1913 ; right subtemporal decompression 
and drainage. Second, December 2, 1913 — 2 months after first operation; 
left subtemporal decompression and drainage. 

Discharged December 12, 1913 — 10 days after second operation. 

Family history negative ; no other children ; no miscarriages for mother. 

Personal History. — First child, full term, difficult labor requiring instru- 
ments ; child bluish for several hours after birth. One hour after birth, baby 
had a general convulsive twitching of both arms and of both legs' and this 
continued each day for several minutes during the following week. Great 
difficulty in swallowing during this period. The convulsive seizures now 
ceased and the condition of the child so improved that he was considered 
a normal child at one month of age, and it was not until 7 months of age 
that it was observed that both arms and both legs were slightly stiff and 
that they were not being used freely. This stiffness and spasticity of the 
arms and legs gradually increased; a definite adductor contraction of the 
thighs was noticed at one year of age and a double Achilles' contracture at 
15 months of age. The general development of the child was also delayed in 
that he could not hold up his head until one year of age, could not sit up 
alone until 2 years of age, and was unable to stand until 4 years of age, but 
never alone and always requiring support. During this time, a ' 'fainting' ' 
spell occurred on the average of one each month, but not always associated 
by a "shaking" of the arms and legs; during the past 4 years, there have 
occurred only 3 general convulsive seizures — the last one being 2 months 
ago. The stiffness and spasticity of the arms and legs, associated with 
contractures at the knees, ankles, elbows and wrists, gradually increased 
during these years, so that the child was unable to stand alone until 6 years 
of age and was first able to walk alone and with great difficulty and awk- 
wardness only at 8 years of age (2 years ago) ; the knees are closely adducted 
in the ' ' scissor ' ' type of gait and both heels are so elevated by the extreme 
Achilles contractures that the child can only stand and walk upon the toes. 
The mentality has been greatly retarded. Speech has never been intelligent 
except to mother, who also complains of the extreme irritability of the child. 
Examination upon admission (10 years after birth and injury). — Tem- 
perature, 98.6°; pulse, 78; respiration, 24. Rather poorly nourished. A 
typical condition of spastic diplegia with flexor contractures at both knees 
and ankles and both arms flexed at the elbows and wrists with the hands in 
the position of pronation ; healed ' ' sores ' ' on the inner sides of both knees 
due to their rubbing in attempting to walk, owing to the marked adductor 
spasm of both thighs. Neither heel can touch the ground, as the contracture 



OCCURRING AT THE TIME OF BIRTH 



687 



of both Achilles tendons is marked. Neither wrist can be extended nor the 
arms straightened at the elbows on account of the contractures of the 
flexor muscles. The use of the hands is very limited and the movements of 
the arms very uncertain and awkward. The patient has the greatest diffi- 
culty in walking — waddling in a jerky manner and most uncertain, the 
patient attempting to hold to any support. Frequent facial movements of an 
athetoid character with continuous drooling from the mouth. Mentality 
markedly retarded — Simon-Binet tests indicate an age of about 6 years; 
the unintelligible speech, however, and the great awkwardness of the hands 
interfered very much with the accuracy of the mental tests. Much diffi- 
culty in walking — waddling in a jerky manner and most uncertain, the 
unstable emotionally — has fits 
of temper and "tantrums." 
Hearing negative ; otoscopic 
examination negative. Pupils 
equal and react to light nor- 
mally. Reflexes — patellar very 
much exaggerated but equal ; 
double patellar and ankle 
clonus ; double Babinski, 
Oppenheim and Gordon 
reflexes ; abdominal reflexes 
depressed but equal; deep 
reflexes of both arms equally 
exaggerated. Fundi — retinal 
veins dilated and their walls 
thickened with new tissue for- 
mation ; nasal halves and tem- 
poral margins of both optic 
disks blurred by edema ; much 
new tissue formation, causing 
both disks to be slightly paler 
than normally — a mild condi- 
tion of secondary optic atrophy. Vision 14/20 in each eye. Lumbar punc- 
ture: clear cerebrospinal fluid under increased pressure (approximately 
24 mm.) ; Wassermann test negative. X-ray (Doctor A. J. Quimby") — 
"signs of an increased intracranial pressure in the convolutional thinning- of 
the vault, especially in the frontal and occipital areas" (Fig. 207). 

Treatment. — The presence of a high intracranial pressure sufficient to pro- 
duce secondary changes of the optic nerve disks — whether the intracranial 
lesion can be localized or not and whether the diagnosis is one of intra- 
cranial tumor, hydrocephalus, hemorrhage or what not — the therapeutic 
indication is to lessen this increased intracranial pressure, either by means 
of medicine or by the operation of cranial decompression; medicine being 
of no real value in these patients, it was decided to afford this patient a 
chance of improvement by means of a subtemporal decompression and drain- 
age. The clinical history of a difficult labor immediately followed by 
convulsive twitchings and then later by an increasing spasticity of both 




Fig. 207. — Convolutional markings of pressure atrophy 
of the inner table of the vault in a boy of ten years having a 
prolonged increase of the intracranial pressure due to a supra- 
cortical hemorrhage at birth; marked improvement follow- 
ing the operation of bilateral decompression and drainage. 



688 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

arms and legs associated with mental retardation, occasional epileptiform 
spells and emotional instability and the persistent increased intracranial 
pressure — these facts wonld indicate a condition of supracortical hemor- 
rhage at the time of birth and later, the development of an external hydro- 
cephalus due to the partial blockage of the stomata of exit in the cortical 
veins of the cerebrospinal fluid, so that a severe condition of cortical edema 
is present. The lowering of this increased intracranial pressure by means of 
a subtemporal decompression and drainage and, if necessary, a bilateral sub- 
temporal decompression and drainage is essential in order that an improve- 
ment be possible. 

Operations (First, October 3, 1913 — 10 years after birth and injury). — 
Right subtemporal decompression and drainage : usual vertical incision, bone 
removed, and no complications, except for the thinness of the bone. Dura 
thickened, whitish and under high tension; upon incising it, much cere- 
brospinal fluid welled through the dural opening, exposing a very edema- 
tous ' ' wet ' ' cortex ; above the Sylvian fissure was a definite supracortical 
cystic formation of a former subarachnoid hemorrhage — about 1 cm. in 
thickness ; upon puncturing its outer wall, a small amount of straw-colored 
fluid escaped from it. About the vessels in the sulci, both above and below 
the Sylvian fissure, was a whitish induration — most probably the remnant 
of the subarachnoid hemorrhage collected in the sulci and there becoming 
organized. At the end of the operation, the brain pulsated slightly and 
the cortical protrusion lessened, so that it was possible to approximate the 
edges of the overlying temporal muscle without damage to the cortex. Usual 
closure with 2 drains of rubber tissue inserted. Duration, 50 minutes. 

Post-operative Notes. — Uneventful operative recovery; incision healed 
per primam, so that patient could be discharged on the eighth day after 
the operation ; the decompression area bulged tensely but pulsated slightly 
and it was hoped that a bilateral decompression would not be necessary. 
This patient was repeatedly examined during the following 2 months and 
although a definite improvement occurred in the lessening of the spasticity of 
both the arms and legs, yet the decompression area bulged so tensely as a re- 
sult of the intracranial pressure, that it was deemed advisable to perform a 
left subtemporal decompression in order to lower this pressure still more. 

Second Operation (December 2, 1913 — 2 months after first operation). — 
Left subtemporal decompression and drainage : usual vertical incision, bone 
removed, and no complications ; the bone, however, was very thin — not much 
thicker than paper (due to pressure atrophy). Dura (as at first operation) 
was whitish, thickened and tense, and upon incising it a large quantity of 
cerebrospinal fluid gushed through the dural opening ; upon enlarging the 
dural opening, a supracortical cystic formation extended upward beyond 
the Sylvian fissure and the upper edge of the dural opening as at the first 
operation; extensive cloudy induration about the vessels in the sulci. At 
first, the cerebral cortex protruded, but as the escape of much cerebrospinal 
fluid continued, this bulging lessened and the cerebral pulsation became 
almost normal. Usual closure with 2 drains of rubber tissue inserted. 
Duration, 45 minutes. 

Post-operative Notes. — Uneventful operative recovery in that the incision 






OCCURRING AT THE TIME OF BIRTH 689 

healed per primam and it was possible for the patient to be discharged on the 
tenth day after operation. The parents were advised to continue the massage 
and exercises just as before the operations — also the advisability of this 
patient attending a "special" school. 

Examination (April 13, 1913 — 16 months after second operation). — The 
marked physical and mental improvement of this patient is very striking; 
not only has the spasticity lessened to such a degree that the patient can 
now walk easily although awkwardly, but a much freer use of the hands 
has resulted and the mental change is so marked that his teachers in school 
are most enthusiastic regarding his progress. It is now possible to under- 
stand his speech and he is so much more stable emotionally that he can 
be controlled without difficulty and his "fits" of temper are of very rare 
occurrence. No ' ' fainting ' ' spells or convulsive seizures have occurred since 
the first operation. Drooling from the mouth only occasionally occurs and 
only when the patient becomes excited. Both decompression areas bulge 
slightly beyond the flush of scalp ; pulsation normal. Pupils equal and react 
normally. Reflexes — patellar active but equal; exhaustible right ankle 
clonus and double Babinski; deep reflexes of both arms active but equal. 
Fundi — retinal veins enlarged; lower nasal margins of both optic disks 
slightly blurred by edema ; the secondary new tissue formation persists as 
before the operations. It is now possible to flex both feet dorsally to a right 
angle, so that both heels can touch thei floor ; adductor spasm of both thighs 
has lessened very much but it is still present; both arms can now be 
straightened at the elbow and the flexor contractures at both wrists are 
greatly improved (Fig. 208). The continuance of the routine daily massage 
and exercises is advised as before the operation. 

Last Report (May 20, 1919 — 16 years after birth and 65 months after 
operation). 

Patient has continued to improve in every way — especially mentally and 
physically; speech is now intelligible although the words are slurred at 
times, and no convulsive seizures have occurred. "In every way, George 
is more like a natural boy." 

Remarks. — The continued improvement of this patient is most gratifying 
and especially when the condition is remembered as being such an extreme 
one of spastic diplegia — the greatest difficulty in walking alone, the restricted 
use of the hands, the retarded mentality, the unintelligible speech and the 
emotional instability and occasional epileptiform seizures — this condition 
in a boy of ten years of age, and, within a period of 6 years following the 
operations and a lowering of the increased intracranial pressure, the con- 
dition of this patient is so improved both physically and mentally that he 
no longer seems to be the same boy. He now walks alone to school where 
his mental progress has been most rapid ; he is able to use both hands more 
freely and writes fairly easily ; his speech is intelligible to all and lie is emo- 
tionally normal as other boys of his age — and most important— the absence 
of convulsive seizures. All of this improvement has followed since the 
lowering of the increased intracranial pressure by means of the two sub- 
temporal decompressions. 

The presence still of a slight increase of the intracranial pressure could 

44 



690 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 






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Fig. 208. — Marked improvement of the condition of spastic diplegia in a boy of 10 years of age following a 
bilateral decompression and drainage to lower the high intracranial pressure. 



OCCURRING AT THE TIME OF BIRTH 691 

now undoubtedly be avoided in similar patients by the use of the linen 
strands for a permanent and more complete drainage of the partially 
blocked cerebrospinal fluid — the condition in so many of these patients 
being* one really of external hydrocephalus resulting from the partial block- 
age of the excretion cerebrospinal fluid through the stomata of exit in the 
walls of the cortical veins in the sulci ; at present, all of these patients having 
very "wet," edematous brains are treated by this means of drainage 
thus making possible the lowering of the increased intracranial pressure to 
normal and the probability of its remaining normal. 

The pressure atrophy of the bones of the vault to the extent of thinning 
them to the thickness of only a sheet of paper is quite common in these older 
patients in whom the intracranial pressure is high and prolonged over a 
period of years ; rontgenograms are important in these patients in confirming 
the signs of increased intracranial pressure as revealed by the ophthalmo- 
scope and the spinal mercurial manometer; negative rontgenograms, how- 
ever, do not indicate the absence of an increased intracranial pressure. 

Case 184. — Chronic severe brain injury occurring at birth and associated 
with a supracortical hemorrhage and a resulting spastic diplegia; an 
increased intracranial pressure. Bilateral subtemporal decompression. 
Marked improvement. 

No. 545. — John. Sixteen years. White. School. U. S. 

Admitted April 16, 1916 — 16 years after birth and injury. Poly- 
clinic Hospital. Referred by Doctor John A. Bodine. 

Operations.— First, April 23, 1916; second, May 3, 1917 (12 months 
later). Left and right subtemporal decompressions and drainage. 

Discharged May 16, 1917 — 13 days after second operation. 

Family history negative ; four sisters living and well ; father and mother 
living and well and no history of nervous disease in the families of 
either parents. 

Personal History. — Third child, full term, difficult labor requiring in- 
struments; "blue baby," becoming normal in appearance in three days; 
no cranial injuries noted ; no convulsive seizures. Some difficulty in nursing 
the child in that there was, apparently, difficulty in swallowing and much 
regurgitation. Child was considered, however, a normal child until the 
eighth month, when it was noticed that both legs were slightty stiff — right 
one more than left, and also the arms possibly stiffer than usual. Child 
did not progress normally in that he was unable to hold up his head until 
the fifteenth month, could not sit alone until the twenty-sixth month and 
the stiffness of the arms and legs became more marked as the child became 
older ; speech was also delayed until thirty months of age and even then only 
monosyllables were used and with much slurring and indistinctness ; at 
3 years of age, the incoordination of movements became more marked 
and although the child learned to walk at forty-six months of age, yet he 
did so with great difficulty and awkwardness, having a typical spastic gait 
associated with much muscular incoordination ; athetoid movements now 
became more noticeable. The right arm and the right leg were always 
stiffer and more awkward than the left arm and the left leg — the right foot 
dragging. The condition was diagnosed as * 'Little's disease" and the 



6 9 2 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

routine treatment of massage and exercises advised but the prognosis was 
considered absolutely bad; no ophthalmoscopic examinations or lumbar 
punctures were performed to estimate accurately the presence or not of an 
increased intracranial pressure and thus the condition was not differ- 
entiated from those patients having a spastic paralysis due to a lack of 
development and naturally not having an increased intracranial pressure. 
During the past few years, the condition of spastic paralysis of both arms 
and of both legs has persisted together with the marked impairment of 
speech, so much so that the patient has great difficulty in making himself 
understood — the mentality being only slightly impaired. No convulsive 
seizures have occurred. 

Examination upon admission (16 years after injury). — Temperature, 
98.6°; pulse, 80; respiration, 24; blood-pressure, 118. Fairly well-devel- 
oped and nourished. Marked spastic paralysis of both arms and legs — the 
latter more affected; both legs are adducted so that the knees tend to 
cross ; legs slightly flexed at the knees and a definite talipes equinus is pres- 
ent — right more than left ; he walks with much difficulty and awkwardness, 
dragging the right foot. Both arms stiff but less so than the legs, and no 
contractures; right arm more impaired than the left; on attempting to 
use the hands, the coarse tremor and incoordination increase. The speech 
is markedly impaired in that all of the words are slurred and indistinct, 
and it is with difficulty that he can be understood. Marked impairment in 
swallowing so that occasionally liquids return by the nose. Mentality 
slightly impaired — the Simon-Binet tests registering an age of 12 years 
plus rather than the actual age of 16 years. The emotional reactions are 
fairly normal. Pupils : equal and react to light and accommodation nor- 
mally; no nystagmus; no ocular paralyses. Reflexes: patellar — both exag- 
gerated, right more than left; inexhaustible patellar and ankle clonus; 
bilateral Babinski, Oppenheim and Gordon reflexes; abdominal reflexes 
present and equal; deep reflexes of both arms and masseteric reflexes in- 
creased. Fundi — retinal veins slightly enlarged with their walls thickened ; 
both optic disks possibly paler than normally, with a definite edematous 
obscuration of the nasal margins ; both physiological cups shallow from con- 
nective tissue formation. Lumbar puncture — clear cerebrospinal fluid 
under increased pressure (approximately 16 mm.) ; Wassermann test 
negative and cell count was 4 cells per c.mm. X-ray (Doctor W. H. 
Stewart ) — ' ' negative. ' ' 

Treatment. — The history and the presence of an increased intracranial 
pressure, associated with a spastic diplegia, more on the right side than on 
the left side and with only slight mental impairment, made advisable the 
operation of left subtemporal decompression to lower this increased pressure 
in the belief that a definite improvement of this patient would result, even 
at this late date, following the original intracranial injury 7 "; the absence 
of convulsive seizures was also an encouraging prognostic factor in making 
the operation advisable. 

Operation (16 years after injury). — First, left subtemporal decompres- 
sion and drainage : usual vertical incision, bone removed, and no compli- 
cations. Dura thickened, whitish and under high tension ; upon incising it, 



OCCURRING AT THE TIME OF BIRTH 693 

clear cerebrospinal fluid spurted to a height of 3 inches, and upon en- 
larging the dural opening a very "wet/' edematous cortex tended to pro- 
trude but did not rupture, owing to the rapid escape of much cerebrospinal 
fluid. Below the fissure of Sylvius, the cortex was apparently normal, but 
extending" down to the Sylvian fissure was a cystic supracortical formation 
lying beneath the arachnoid and filled with a straw-colored fluid; upon 
excising its outer wall and allowing this fluid to escape, the underlying 
compressed cortex was enabled to rise after the cyst itself collapsed ; several 
of the underlying cerebral convolutions appeared pale and atrophied from 
pressure ; this cystic formation was at least 1 cm. in thickness and extended 
upward over the parietal lobe as far as could be seen beyond the bony edge 
of the decompression opening. About the vessels in the Sylvian fissure was a 
whitish induration due to the organization of the former hemorrhage about 
the vessels, and this same condition was present about the vessels in the 
sulci. (Apparently the cystic formation seen at operation was the lower por- 
tion of an extensive hemorrhagic supracortical cyst resulting from the former 
intracranial hemorrhage at the time of birth and as both sides of the 
patient's body are affected, it is most probable that the cortex of the other 
hemisphere is also similarly impaired.) At the end of the operation, the 
cortex pulsated almost normally. Usual closure with 2 drains of rubber 
tissue inserted. Duration, 35 minutes.. 

Post-operative Notes. — Uneventful convalescence; incision healed per 
primam and the patient was discharged on the twelfth day ; the decompres- 
sion area bulged slightly but pulsated almost normally, and it was decided 
to wait for a period of 6 months to 1 year in the hope that the increased 
intracranial pressure would be entirely relieved by this one operation, as 
would be indicated by the usual tests of intracranial pressure and the 
' ' sinking-in " and depression at the site of the decompression opening; the 
routine treatment of massage, exercises, etc., was advised as before. 

During the following year, the patient made a definite improvement in 
that the spasticity of both arms and legs lessened, but more of the right side 
of the body than of the left, so that the patient now could use the right arm 
and right leg better than the left arm and left leg. (This is an interesting 
observation and of frequent occurrence in these patients — a left decompres- 
sion causing a more marked improvement and lessened spasticity of the 
right side of the body than of the left side and vice versa, and this is what 
one would naturally expect.) The speech had improved so that it was more 
intelligible and his school teacher reported a greater mental capacity and 
aptitude. The decompression area, however, continued to remain flush with 
the surrounding scalp and it did not become depressed so that a, bilateral 
decompression was considered advisable. 

Examination upon second admission (April 26, 1917 — 17 years after 
the injury and one year after operation). — Temperature, 98.6° ; pulse. SO: 
respiration, 24; blood-pressure, 120. Definite spastic diplegia but much 
less than one year ago ; the stiffness and awkwardness of the left arm and left 
leg are now greater than that of the right arm and right leg: the right leg 
no longer drags and patient walks less upon the toes than before. The 
speech has markedly improved and he can be understood with less difficulty ; 



694 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

no impairment of swallowing. Mentality has definitely improved — Simon- 
Binet tests now registering him as of the age of almost 15 years ; his emo- 
tional control is also better. Pupils present and react to light and accommo- 
dation. Reflexes — patellar very active, left possibly more than right; ex- 
haustible right patellar and ankle, clonus, but inexhaustible left patellar and 
ankle clonus ; double Babinski, Gordon and Oppenheim reflexes ; abdominal 
reflexes present and equal ; deep reflexes of both arms increased — left pos- 
sibly more than right. Fundi — retinal veins enlarged and a definite blur- 
ring of the nasal margins of both optic disks — left possibly more than right ; 
otherwise the fundi are the same as at the preceding examinations of one year 
ago. Lumbar puncture — clear cerebrospinal fluid under increased pres- 
sure (13 mm.). The site of the former decompression over the left side of 
the head pulsates but it is not depressed and remains flush with the sur- 
rounding scalp ; at times, it bulges. 

Treatment. — The increased intracranial pressure having been lessened 
but not sufficiently to permit the greatest ultimate improvement, it was 
considered advisable to perform a right subtemporal decompression in the 
belief that a greater lessening of the pressure would make possible a still 
greater improvement. 

Second Operation (17 years after injury and one year after first opera- 
tion). — Right subtemporal decompression and drainage: usual vertical inci- 
sion, hone removed, and no complications. Dura thickened, whitish and 
tense ; upon incising it, clear cerebrospinal fluid spurted to a height of one 
inch and upon enlarging the clural opening the underlying edematous cortex 
bulged but did not rupture. No definite fibrous or cystic formation ascer- 
tained, but about the vessels in the sulci was a cloudy whitish thickening of 
connective tissue — the organization of the former supracortical hemorrhage 
which could not be entirely absorbed and lying in the sulci. (It is the block- 
age in this manner of the stomata of exit of the cerebrospinal fluid in the 
walls of these cortical veins in the sulci which causes the "wet" edematous 
condition of the brain — in reality, a mild condition of external hydro- 
cephalus ; the more complete this blockage, the greater is this cortical edema 
and excess cerebrospinal fluid. ) So much cerebrospinal fluid escaped that by 
the end of the operation, the cortex pulsated normally. Usual closure with 
2 drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes.— Uneventful convalescence ; incision healed per 
pnmam and the patient was discharged on the thirteenth day. At dis- 
charge, the decompression areas w r ere both slightly depressed beneath the 
flush of scalp. The usual routine treatment of these patients of massage, 
exercises and general hygiene was advised — just as before the operation. 

Examination (January 29, 1918 — 9 months after second operation). — 
The improvement of the patient has rapidly progressed in that the spasticity 
of the arms and legs has markedly lessened so that now the patient can use 
both hands and can walk with much less difficulty and awkwardness than 
ever before; he is able to ride a bicycle to school and his speech has so 
improved that it is possible for him to be in the classes with the other boys ; 
he has even played baseball, but naturally with difficulty. A definite im- 
provement mentally has also occurred and he is now more interested in things 






OCCURRING AT THE TIME OF BIRTH 695 

and desires to learn. Not so irritable and "gets along" with the other 
boys much better. Both decompression areas are depressed and pulsate 
normally. Reflexes — patellar less active than before, right being possibly 
greater than left ; exhaustible patellar and ankle clonus ; double Babinski 
reflexes persist; deep reflexes of both arms increased but much less than 
before. Fundi — retinal veins possibly slightly enlarged but no edematous 
blurring of the nasal margin of either optic disk can be observed ; the pallor 
of both disks naturally persists due to the former scar tissue formation. 
Visual acuity 16/20 in each eye — the same as before the operations. No lum- 
bar puncture was performed as both decompression areas were depressed and 
therefore no marked increase of the intracranial pressure could be present. 

Last Report (March 6, 1919 — 23 months after last operation). — Mother 
writes : "Jack has continued to improve during the past year, both in his 
physical condition — walking particularly — and also in his school work. The 
places where the operations were made are sunken but their beating is 
still visible. Fie does not complain of headaches and his entire condition 
is most pleasing. ' ' 

Remarks. — It is to be regretted that this patient could not have been 
operated upon earlier — at the time of birth or surely as soon as the results 
of tho intracranial condition first appeared — within one year after birth; 
if such a marked improvement can be obtained sixteen and seventeen years 
after the cranial injury, surely the earlier operation would not only pre- 
vent the greater physical impairment, but it would have afforded the patient 
the opportunity of developing more normally. It is most surprising that 
this patient has improved so much as has occurred since the operation, and 
it merely emphasizes again that the intracranial lesion in this patient and in 
the vast majority of patients similarly impaired and having an increased 
intracranial pressure, that there is not a primary destruction of the cerebral 
cortex but that the function of the cortical cells is impaired by the increased 
intracranial pressure resulting both from the supracortical hemorrhage and 
the partial blockage of the excretion of the cerebrospinal fluid, producing 
in most of these patients a mild condition of external hydrocephalus. By 
lowering this increased intracranial pressure by means of a decompression 
and, if necessary, a bilateral decompression, then the cortical cells are no 
longer compressed to the extent as before and therefore they are now able 
to functionate more normally. 

One of the earliest signs of improvement following the successful lower- 
ing of this increased intracranial pressure is the lessening of the spasticity 
and awkwardness of the affected arm or leg, a greater ease of speech and most 
fortunately an improved mentality, so that these patients come out of their 
"haze," become more interested in their surroundings and are thus enabled 
to develop mentally ; their emotional control becomes greater and therefore 
they are more stable. 

Naturally, in these older patients it has never been suggested or intimated 
that their condition can be cured, so that they would become normal just as 
if the condition had not happened; they can be improved, however, and in 
the milder patients the condition can be so benefited that they approximate 
normality, but the older they become without a lowering of this increased 



6 9 6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

intracranial pressure, just so much less can be expected of a later relief of the 
increased intracranial pressure. The younger the patient, the greater chance 
of affording the greatest ultimate improvement (the intracranial lesion 
being the same), and naturally the ideal time for the operation is within 
several days after birth when the free supracortical hemorrhage can be 
immediately drained in fluid form, and in this manner not only is the 
increased intracranial pressure immediately lowered, but the secondary com- 
plication of a blockage of the excretion of the cerebrospinal fluid is thus 
anticipated and prevented. If in all doubtful cases following birth — with 
and without the use of instruments — and the child is abnormally quiet or 
surely in the presence of convulsive twitchings, if a lumbar puncture is 
then performed and an increased pressure ascertained and especially in 
the presence of blood in the cerebrospinal fluid, then an immediate drainage 
of the subdural blood by means of repeated lumbar punctures and spinal 
drainage or by a modified subtemporal decompression operation would 
afford these unfortunate children their opportunity for the greatest ulti- 
mate recovery — both of life and of normality. 

Case 185. — Chronic severe brain injury at birth associated with an 
extensive supracortical hemorrhage and a resulting spastic paraplegia and 
mental retardation; an increased intracranial pressure. Bilateral subtem- 
poral decompression. Marked improvement. 

No. 19. — Mary. Twelve years. White. Special school. U. S. 
Admitted October 2, 1913 — 12 years after birth and injury. Ortho- 
pedic Hospital. Referred by Doctor B. P. Farrell. 

Operation October 14, 1913. Bilateral subtemporal decompression 
and drainage. 

Discharged November 6, 1913 — 22 days after operation. 
Family history negative. 

Personal History. — First child, full term, normal labor apparently — no 
instruments being required ; no convulsive seizures. Bottle baby. The child 
was considered normal in every way until the eleventh month, when it was 
noticed that both legs were slightly stiff, and this spasticity gradually 
increased during the next six months until the legs became adducted and 
flexed at the knee, together with marked contraction of both Achilles tendons ; 
daily massage and exercises were given both in the hospital and at home, 
and yet the spasticity gradually became more and more marked. No definite 
impairment of the arms observed. The child has never been able to walk 
or to stand alone. During the past eight years, three operations for lengthen- 
ing both Achilles tendons have been performed with a resulting improve- 
ment during the following 6 to 8 months, when the contractures gradually 
returned as before. Mentality has become definitely impaired but it is com- 
paratively slight compared with the extensive spastic paralysis of both legs. 
No convulsive seizures at any time. Patient has received excellent hospital 
treatment of massage and exercises daily, but no permanent improvement 
has been obtained. 

Examination upon admission (12 years after birth and injury). — Tem- 
perature, 98.6° ; pulse, 82; respiration, 26. Well-nourished child having a 
marked spastic paraplegia associated with flexor contractures of both legs 



OCCURRING AT THE TIME OF BIRTH 697 

at the hips and at the knees, and a bilateral plantar flexion due to the marked 
contraction of both Achilles tendons ; child stands when supported upon the 
toes with the "scissor" type of adduction of both thighs. Both arms are 
used comparatively freely and with little or no impairment. Patient talks 
with only a slight retardation and difficulty. A cursory Simon-Binet test 
registers an age of nine years. Hearing negative ; otoscopic examination 
negative. Pupils equal and react normally. Reflexes — patellar very much 
exaggerated but equal ; double patellar and ankle clonus ; double Babinski, 
Gordon and Oppenheim reflexes; abdominal reflexes depressed but equal; 
deep reflexes of both arms. — possibly more active than normally. Fundi — 
retinal veins dilated ; nasal margins of both optic disks blurred by edema ; 
new tissue formation about the margins of both optic disks which are pos- 
sibly paler than normally — a mild secondary optic atrophy. Vision 18/20 
in both eyes. Lumbar puncture — clear cerebrospinal fluid under increased 
pressure (approximately 18 mm.) ; Wassermann test negative. X-ray 
report — ' ' negative. ' ' 

Treatment. — The presence of the increased intracranial pressure, as indi- 
cated by the ophthalmoscope and lumbar puncture findings, makes advisable 
its operative relief by means, of a subtemporal decompression, in the belief 
that its lowering would permit a lessening of the spasticity, an improvement 
of the mentality and the greatest ultimate recovery of function in this 
patient — in spite of the advanced age and the severity of the spastic para- 
plegia to the extent of an inability to stand alone or to walk ; the danger of 
future convulsive seizures is also very great indeed. 

Operations (12 years after birth and injury). — Bilateral subtemporal 
decompression and drainage. First, right decompression : usual vertical 
incision, bone removed, and no complications. Dura whitish, thickened and 
tense ; upon incising it, clear cerebrospinal fluid spurted through dural open- 
ing and upon excising its outer wall, a small amount of straw-colored fluid 
escaped, permitting the underlying edematous cortex to protrude. Supra- 
cortical vessels were very much dilated and about them in the sulci was a 
whitish induration, especially about those above the Sylvian fissure, where 
the arachnoid was very much thickened and of a hazy appearance — as of a 
cyst formation; upon puncturing it, however, clear cerebrospinal fluid 
escaped. The cerebral convolutions appeared possibly paler than normally. 
Owing to the continued protrusion of the cerebral cortex, it was feared that 
a rupture of it might occur unless a left subtemporal decompression was 
immediately performed arid this was done before the closure of the right 
decompression was attempted. 

Second Operation. — Left decompression : usual vertical incision, bone re- 
moved, and no complications. Dura thickened, whitish and almost as tense 
as at first operation ; upon incising dura, clear cerebrospinal fluid welled out 
under tension, revealing a definite cystic formation above the Sylvian fissure 
and upon excising its outer wall, a small amount of straw-colored fluid 
escaped, permitting the underlying convolutions to rise. Much whitish 
induration about the vessels in the sulci. At the end of the operation, the 
cortex pulsated almost normally due to the escape of much cerebrospinal 



6 9 8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

fluid. Usual closure of both decompression openings with 2 drains of rub- 
ber tissue inserted. Duration, 75 minutes. 

Post-operative Notes. — Uneventful operative recovery; both incisions 
healed per primam; even at discharge upon the twenty-second day after 
operation, there was a definite lessening- of the spasticity and a brighter, 
more alert mental condition. The usual routine treatment of massage and 
exercises was continued just as before the operation. 

Examination (April 13, 1915 — 18 months after operation). — An excel- 
lent improvement has occurred in that the patient was able to walk with 
support within 8 months after the operation and she now walks alone and 
erect with only a slight ' ' waddle " ; a brace devised by Doctor Farrell has 
been most effective in aiding the walking. Mentality is much improved and 
the child has now advanced to a "special" sixth grade. Much better control 
emotionally. Decompression areas protrude slightly beyond the flush of 
scalp ; normal pulsation. Reflexes — patellar very active but equal ; no 
patellar nor ankle clonus, but double Babinski reflexes persist; abdominal 
reflexes present and equal ; deep reflexes of both arms negative. Fundi — 
retinal veins enlarged; lower nasal margins of both optic disks slightly 
blurred by edema ; new tissue formation remains as before the operations. 
Vision — 18/20 in each eye. 

Last Beport — January 20, 1919 — 63 months after operations. Report 
of district nurse : ! ' Mary has continued to improve in her walking but 
she still uses braces ; she can move about more freely. She is very bright in 
her mind." A report of the condition of this patient will be made in detail 
later — at the end of a ten-year period. 

Remarks. — The excellent improvement occurring in this patient, even 
at the late age of 12 years following a lowering of the increased intracranial 
pressure due to a partial blockage of the excretion of the cerebrospinal 
fluid by means of a former supracortical hemorrhage with new tissue forma- 
tion about the supracortical veins and the presence of a supracortical hemor- 
rhagic cyst itself — this marked improvement, both physically and mentally, 
has been a most gratifying one. Although this patient is not a normal child 
in that the walking is definitely impaired and awkward, yet she is able to 
walk and her mental improvement has been so striking that it is not only 
a most encouraging result but a cause of great regret that the operatrve 
lessening of the increased intracranial pressure could not have been per- 
formed years earlier and in this manner a much greater ultimate recovery 
of function would have been possible ; as is now well realized, the ideal 
treatment is within several days after birth, when the supracortical hemor- 
rhage can be itself drained rather than at a later operation to lessen the effects 
and results of this supracortical hemorrhage — the partial blockage of the 
excretion of the cerebrospinal fluid into the cortical veins with the formation 
of a mild condition of external hydrocephalus. It is most difficult to con- 
ceive that any brain injury can occur, and especially if its effects of pressure 
are prolonged, that the patient can become, no matter what the treatment, 
a perfectly normal individual — mentally, emotionally and physically; it is 
only in the early patients — as soon as possible following the intracranial 
lesion, that it is possible for these patients to approximate normality, and all 



OCCURRING AT THE TIME OF BIRTH 699 

medical efforts should be directed toward the early diagnosis of the lesion 
and its appropriate treatment. 

The persistence of a slight bulging of both operative areas indicates an 
increase of the intracranial pressure, and that in this patient both decom- 
pressions and drainage were not sufficient to decrease the intracranial pres- 
sure down to its normal amount. To avoid this complication, it has been the 
practice in our clinic during the past two years to treat these patients just 
as are the patients having the condition of external hydrocephalus — that 
is, through the decompression opening, several linen strands are inserted 
subdurally and beneath the arachnoid and are brought out through the 
temporal muscle and fascia, into the subcutaneous tissues of the scalp in a 
stellate manner, and thus it is believed that a permanent drainage of the 
partially blocked cerebrospinal fluid is possible by means of the numerous 
lymphatics of the scalp ; at least, since using this latter method of operative 
procedure and drainage, it has been possible to lower the intracranial pres- 
sure to normal in these patients so that no protrusion of the decompression 
areas has occurred. 

The absence of convulsive seizures in this patient, and especially in view 
of the operative findings of the supracortical hemorrhagic cyst and the new 
tissue formation about the cortical veins in the sulci — a sufficient cortical 
irritant to produce convulsive seizures in most patients — is surprising and 
yet a very common observation in almost one-half of these patients. Why 
they do not have convulsions and yet practically the same intracranial 
lesion is present, may possibly be due to a greater nerve stability — whether 
due to ancestry or to some other factor. Naturally, the prognosis 1 is much 
more favorable in the patients who have not had convulsions or at least 
not since early childhood than in the ones in whom convulsions are of fre- 
quent occurrence. 

Case 186. — Chronic cranial injury occurring at the time of birth and 
followed by convulsive twitchings, spastic diplegia and an increasing intra- 
cranial pressure. Right subtemporal decompression and drainage of large 
brain abscess. Death. Autopsy. 

No. 1043.— Elizabeth. Twelve weeks. White. U. S. 

Admitted November 20, 1918 — 12 weeks after birth and injury. Audu- 
bon Hospital. Referred by Doctor M. H. Bass. 

Operation. — November 27, 1918. Right subtemporal decompression 
and drainage of cerebral abscess. 

Discharged December 3, 1918 — 6 days after operation. 

Died April 17, 1919 — 6 months after birth and 3 months after opera- 
tion. Acute internal hydrocephalus. 

Family history negative ; no other children ; no miscarriages for mother. 

Personal History. — First child, full term, difficult instrumental labor 
(high forceps) ; much difficulty in resuscitating the child. Three days after 
birth, a temperature of 103° developed and it was noticed that both arms 
and both legs could not be moved ; this continued for 4 weeks, when it was 
observed that both arms and both legs were becoming stiff, the head was 
held backward, the neck slightly stiff and a forward arching ol' the back 
(a mild condition of opisthotonos^ ; spasmodic twitchings now appeared in 



7oo DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

the left side of the face, left ami and left leg. lasting for several minutes 
and occurring as frequently as 20 times each day: a general convulsive 
seizure resulted about every three days. During the past 2 months, these 
epileptiform spells have continued together with an increasing spasticity 
of both, amis and legs and a definite enlargement of the head: child has 
not gained in weight and has become very much emaciated. 

E jmination upon admission 12 weeks after birth and cranial in- 
jury). — Temperature. 101.2 : ; pulse. 124: respiration. 34. Very much emaci- 
ated : skin wrinkled, presenting a senile appearance : weight. 12 pounds. 
Body rigid — back arched forward and head held rigidly backward. Child 
loes not notice anything — eyes rolling from side to side. Severe spasticity 
of both arms and legs, especially the left side. Veins of scalp are enk: g 1 
and very extensive. Head is larger than normal with a definite protru- 
sion of both fontanelles. which are very tense, and a marked widening and 
separation of the suture lines, especially the mid-frontal suture. Pupils 
of normal size and reaction to light. Reflexes — patellar, very much exs _- 
gerated. left more than right : no patellar or ankle clonus, but a left Babin- 
ski obtained : abdo min al reflexes absent : deep reflexes of both amis increased 
— left more than right. Fundi : retinal veins enlarged : distinct edematous 
blurring of the nasal halves and the nasal margins of both optic disks which 
are rather white. Lumbar puncture : three attempts were made to obtain 
some cerebrospinal fiuid for examination and to measure accurately its 
pressure, but no fiuid could be obtained — only a small quantity of bl 

this inability to obtain the cerebrospinal fluid at repeated lumbar punc- 
ture was undoubtedly due to a blockage of the cerebrospinal fluid within 
the cranial cavity, so that it was not possible for the fiuid to descend into 
the spinal canal — that is. either the condition of adhesions about the fora- 
men niagnuni or the condition of an internal hydrocephalus . X-ray report 
— " • a distinct overlapping of the bones forming the lambdoidal suture and 
a possible fracture of the occipital bone itself"' ('Fig. 2 

Treatment. — The history of instrumental delivery to be followed within 
3 days by an increased temperature and weakness of the extremities and 
then 4 weeks later, by a spastic paralysis of both arms and legs, epileptiform 
spells of a localized character and then finally by the enlargement of the 
head with protruding tense fontanelles and a separation of the lines of suture 
and the presence of a high intracranial pressure being confirmed by the 
ophthalmoscopic examination, and the X-ray findings of cranial trauma in 
the occipital area — these data all tended to indicate the cranial injury at the 
time of birth followed by a meningeal inflammation (a mild meningitis^ with 
the later development of an internal hydrocephalus which prevented the 
cerebrospinal fluid from descending into the spinal canal. This was the 
tentative diagnosis and the operation of right subtemporal decompression 
and drainage was advised in the belief that the institution of satisfactory 
drainage might prove of benefit to the condition: the operation was ad- 
vised as the only known means of improving the condition by a drainage 
of the internal hydrocephalus. 

Operation (12 weeks after birth and cranial injmy). — Right subtem- 
poral decompression and drainage of a brain abscess : usual vertical incision. 



OCCURRING AT THE TIME OF BIRTH 



701 



bone removed and 110 complications ; no Doyen perforator or burr was used, 
as the bone itself was of a membranous character and it was possible, as in 
all of these babies, to incise the pericranium between the squamous and the 
parietal bones and thus rongeur away the surrounding bone to a diameter 
of 2 inches. Dura thickened and tense so that it bulged ; upon incising it, 
no cerebrospinal fluid escaped, and in order to lessen the high cerebral ten- 
sion for fear that the underlying cortex would rupture, an attempt was made 
to tap the right ventricle by means of the ventricular puncture needle. 
Upon inserting the puncture needle into the upper convolution of the right 
temporal lobe and at right 
angles to the cortex, when it 
had reached a depth of not 
more than 2 cm., a large 
amount of yellowish pus 
welled up through the needle 
and around it, and upon 
enlarging this cortical punc- 
ture opening, over 2 ounces 
of similar pus escaped. 
Pathological report (Doctor 
Jeffries) : "Pure growth of 
a gram-negative bacillus. 
A rubber tube for drainage 
was now inserted into the 
abscess cavity which ap- 
peared to be about 3 inches 
in diameter and filling the 
right temporo-sphenoidal 
lobe and the lower portion of 
the right parietal lobe. The 
cerebral tension immediately 
lessened and no further 
attempt was made to tap the 
ventricle for fear of extend- 
ing the infective process, and 
it was also now considered 
an unnecessary procedure as 
the cerebral tension had been lowered by the drainage of the abscess itself. 
Usual closure with 2 drains of rubber tissue inserted subdurally ; the rubber 
tube drainage of the abscess was naturally left in situ. Duration, 30 minutes. 
Post-operative Notes.' — An excellent operative recovery occurred in 
that the drainage of the abscess continued for 2 days and then 
gradually ceased, so that it was possible to remove the drainage tube 
8 days after the operation, when the abscess cavity itself had apparently 
collapsed; the child gained 3 ounces in weight daily and although the 
convulsive twitchings of the left side of the body continued for several 
days, yet they were much less severe and infrequent than before the opera- 
tion and no general convulsive seizure occurred. The operative incision 



e 




Fig. 209. — An overlapping of the bones forming the 
lambdoidal suture and a possible fracture of the occipital bone 
in a child following an instrumental delivery with resulting 
spastic diplegia and convulsive seizures. A right subtemporal 
decompression to lower the increased intracranial pressure dis- 
closed a large brain abscess, which was drained. (Note the 
position of the head due to the rigid posterior extension of the 
neck to form with the arched spinal column a mild degree of 
opisthotonos.) 



702 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

healed and the general condition of the child had so improved, that it was 
possible for it to be discharged from the hospital on the sixth day after 
operation. During the following month, the general condition of the child 
improved and at times no convulsive twitchings of the left side of the body 
occurred for days ; the operative area, however, began to bulge during 
the fourth week following the operation, and for fear that the abscess was 
being refilled with a purulent secretion, it was decided to explore through 
the operative incision ; nothing abnormal was found, however, except an 
increased intracranial pressure, and it was considered to be better surgical 
judgment not to attempt a ventricular drainage for fear of extending the 
infective process. Following this exploratory incision, the general condition 
of the child improved for a period of 2 months, in that the spasticity 
became less severe, the epileptiform twitches less frequent and at times 
a normal intracranial pressure was disclosed by the ophthalmoscope ; the 
child continued to gain in weight. Four months after operation, the con- 
dition rapidly became worse in that the size of the head enlarged, the fon- 
tanelles bulged tensely and the ophthalmoscope revealed an edematous blur- 
ring of the nasal halves of both optic disks : the child could no longer nurse 
and the condition itself rapidly became so much worse from the acute ven- 
tricular dilatation that it was decided not to attempt any surgical procedure 
of drainage owing to the extreme condition of emaciation and weakness of 
the child: the temperature gradually ascended to 106 plus, the pulse and 
respiration finally could not be counted and the child died from extreme 
weakness apparently and inanition, 6 months after birth and 3 months 
after the operation. 

Autopsy. — Typical hydrocephalic head in the bulging forehead and 
occipital areas and the widely separated suture lines. No fracture of the 
cranial bones found. Operative site negative except for several adhesions 
between the temporal muscle and the underlying cerebral cortex ; there 
were also numerous adhesions at the base, especially subtentorially about the 
foramen magnum. The cerebral convolutions were rather flattened as the 
result of the increased pressure, but otherwise the cortex itself was negative. 
In the right temporo-sphenoidal lobe was a healed abscess cavity of 3 inches 
in length and l!o inches in width ; it was well walled-off from the surround- 
ing tissue. Both lateral ventricles and also the third ventricle were widely 
dilated and filled with a clear cerebrospinal fluid (bacteriological report r 
"'no organisms found"}. Both middle ears contained a purulent secretion. 

Remarks. — Before this patient was operated upon, the diagnosis was 
one of an increased intracranial pressure due most probably to an internal 
hydrocephalus or to an extensive intracranial hemorrhage occurring at the 
time of birth and secondarily followed by a blockage of the cerebrospinal 
fluid. 'The condition had been diagnosed at numerous consultations as 
Little's disease due to a lack of cerebral development and agenesis of the 
cortex, although there were present at the time the signs of an increased 
intracranial pressure which naturally made these diagnoses untenable as 
well as hnpossible.) The operation itself of decompression was advised 
simply to lower the increased intracranial pressure — whether due to a 
blockage of the ventricles themselves or to a former hemorrhae'e or to a 



OCCURRING AT THE TIME OF BIRTH 703 

tumor, or to any condition that would cause a marked increase of the 
intracranial pressure — the presence of an increased intracranial pressure 
being in itself sufficient justification and indication of the necessity of an 
operative lowering of it if the condition of the child was to be improved. 
The finding of a brain abscess at the operation was a surprise and it had 
not been diagnosed, but the operative indication was the same, no matter 
what the intracranial condition happened to be, the therapeutic object being 
to lower the increased intracranial pressure ; in this case of a brain abscess, 
this lowering of the increased intracranial pressure was easily possible by 
means of drainage through the decompression opening ; the risk of the seri- 
ous complication of a meningitis following the drainage of a subcortical 
abscess is lessened by the drainage through a decompression opening by 
means of which the increased intracranial pressure is lessened and the 
surrounding tissues 1 are more enabled to withstand an infective process. 

It is very rare to be unable to obtain cerebrospinal fluid by means of 
a lumbar puncture — a so-called ' ' dry ' ' tap. It does occur most frequently, 
however, when the intracranial condition is due to an internal hydrocephalus 
and especially in the presence of an acute purulent meningitis, since in these 
conditions it is possible for the cerebrospinal fluid to be prevented from 
descending into the spinal canal as the result of adhesions and in the latter 
case from the purulent exudate itself. "Dry" taps, however, should never 
be accepted as such, until several attempts have been made to obtain the 
fluid at lumbar puncture and should only be so considered when it is defi- 
nitely known that the needle is within the dural sac of the spinal canal. 
In this patient, the absence of cerebrospinal fluid at lumbar puncture was 
most probably due to adhesions about the foramen magnum and also to the 
presence later of a complete internal hydrocephalus. The rontgenogram 
disclosing the overlapping of the bones of the occipital area was a possible 
cause originally for the beginning of the infective process and the develop- 
ment of the cerebral abscess ; this is to be doubted very much as there were 
no signs of an underlying meningitis, having been present ; in the presence, 
however, of a purulent secretion in both middle ears, the autopsy findings 
would tend to indicate this as being a possible channel for the source of 
the infection. 

The excellent operative recovery following the drainage of the abscess 
itself was most gratifying and the prognosis was most encouraging following 
the continued post-operative improvement of the general condition of the 
baby ; if an acute blockage of the ventricles had not occurred as the result 
of adhesions subtentorially, it might have been possible for an excellent 
improvement to have been obtained, although the end-result could not have 
been a satisfactory one, owing to the extensive damage to the brain itself 
and to the fact of the extreme severity and degree of the intracranial lesion. 

Case 187. — Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage, producing the condition of severe spastic diplegia. 
mental impairment and convulsive seizures; an increased intracranial pres- 
sure. Bilateral decompression. Two weeks later, at operation to lengthen 
the Achilles tendons, death from ether. Autopsy. 

No. 515. — Edward. Fourteen years. White. Spain. 



7 o4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Admitted February 15, 1915 — 11 years after birth and injury. Poly- 
clinic Hospital. Referred by Sir Victor Horsley. 

Operations. — Bilateral decompression, March 3 and 15, 1915; tendon 
lengthening, March 31, 1915. 

Death March 31, 1915 — immediately following the induction of ether 
narcosis for the operation of tendon lengthening. 

Family history negative; no other children; no miscarriages for mother. 

Personal History. — First baby; full term, prolonged " dry" labor; but 
no instruments; no convulsions after birth and the child was considered 
normal until 6 months of age, when it was noticed that the head was held 
slightly backward and rather stiff. At 7 months of age, it was observed that 
the left leg and the left arm were not being moved as freely as the right 
arm and leg and that the left leg was possibly stiff er than the right leg. 
At 8 months of age, both legs were observed to be stiffer than normally and 
one month later, a definite adduction appeared. Child was able to hold 
up its head at 12 months of age and he was able to sit up at 17 months of 
age. There was no attempt made to talk. The spasticity of both legs and 
of both arms — more on the left side — gradually increased until there devel- 
oped the typical condition of spastic diplegia with adduction of both legs 
in the "scissor" type cf posture and with flexor contractures of both arms 
and legs — always more on the left side. At 3 years of age, the first general 
convulsive seizure occurred with no localizing signs and lasting for a period 
of five minutes; the second seizure occurred 9 years later (2 years ago), 
and since then there has occurred each week 2 general convulsive seizures ; 
no localizing signs, and usually at night. He has attempted to talk but 
cannot make himself understood. Mentality markedly impaired. Patient 
has never been able to stand alone or to walk. No improvement has resulted 
from daily massage and exercises. 

Examination upon admission (14 years after birth and injury). — Tem- 
perature, 98.6°; pulse, 80; respiration, 24; blood-pressure, 114. Rather 
poorly nourished. Patient presents a typical picture of spastic diplegia 
associated with marked flexor contractures of both legs — the left more than 
the right ; double talipes equinus with marked adductor spasm of both 
thighs ; flexion of both arms at the elbows and at the wrists ; both thighs 
flexed upon the trunk and the back is slightly arched. No rigidity of the 
neck. Patient is able to use both arms and legs in a stiff awkward manner — 
the left side being worse than the right. Unable to talk but he can' make 
certain guttural sounds which can be differentiated by the parents as mean- 
ing '"Yes," "No," "I want to," etc. Much difficulty in swallowing — fluids 
frequently returning through the nose. Apparently no impairment of hear- 
ing; otoscopic examination negative. Patient is able to stand upon the 
toes, but he must hold to a chair or other object for support ; attempts to 
walk when supported, but the adduction of both thighs is so marked that he 
has the greatest difficulty in moving one knee beyond the other ; the left side 
is much worse than the right. Pupils equal and react normally. No stra- 
bismus nor nystagmus. Reflexes — patellar exaggerated, left more than 
right ; double patellar and ankle clonus, but a Babinski reflex is obtained 
only on the left foot ; abdominal reflexes depressed but equal ; deep reflexes 



OCCURRING AT THE TIME OF BIRTH 705 

of both arms increased; masseteric reflexes increased equally. Fundi — 
retinal veins enlarged with thickened walls and much new tissue formation 
about them; nasal halves of both optic disks and also their temporal mar- 
gins blurred by edema ; both optic disks rather pale from new tissue forma- 
tion, presenting an appearance of mild secondary optic atrophy; both 
physiological cups shallow with new tissue formation. Lumbar puncture — 
clear cerebrospinal fluid under high intracranial pressure (approximately 
24 mm.) ; Wassermann test negative and the cell count was 5 cells per 
c.mm. X-ray (Doctor A. J. Quimby) — "pronounced convolutional mark- 
ings of increased intracranial pressure." 

Treatment. — The condition of this patient was such an extreme one and 
of such severity, especially in view of the advanced age of the patient, that 
it made the treatment of whatever character of so little value in that it could 
not be conceived that this patient could become normal or even approximate 
normality; that is, even with the most successful outcome, the most that 
could be expected would be an improvement — a lessening of the spasticity 
to the extent of possibly walking, an improved mentality and the ability to 
speak a few words intelligibly. This was fully explained to the parents 
but they felt that if any improvement at all could be offered by an opera- 
tive relief of the high intracranial pressure, then it should be afforded to 
the child. Accordingly, the operation of right subtemporal decompression 
was performed in the belief that the lowering* of the increased intracranial 
pressure would permit a definite improvement of the condition to occur. 

Operations (14 years after birth and injury). — First, right subtemporal 
decompression : usual vertical incision, bone removed, and no complications ; 
bone was unusually thick, vascular and spongy — being almost one-half of 
an inch in thickness along the anterior margin. Dura thickened, whitish and 
tense ; upon incising it, clear cerebrospinal fluid spurted to a height of 4 
inches, revealing a very "wet," edematous cortex beneath the Sylvian 
fissure, while above the Sylvian fissure was a bluish cystic hemorrhagic mass 
lying upon the cortex and possibly within the cortex itself, and extending 
upward beyond the bony edge of the decompression opening. The cortex 
bulged tensely and tended to protrude, but it did not rupture, as much cere- 
brospinal fluid continued to escape so that at the end of the operation the 
cortex pulsated feebly. A portion of the cystic formation became concave 
at each respiration, as if a cortical destruction had occurred at that point. 
The outer wall of the cyst itself was incised, permitting a straw-colored 
fluid to ooze out and causing the outer wall of the cyst to assume a con- 
cave position. The cortex beneath the Sylvian fissure was negative, except 
for the presence of the edema and a cloudy induration about the vessels 
in the sulci; the convolutions themselves were possibly paler and more 
anemic than normally. Usual closure with 2 drains of rubber tissue 
inserted. Duration, 35 minutes. 

Post-operative Notes. — Uneventful recovery in that the incision healed 
per primam and no complication occurred; the decompression area, how- 
ever, protruded tensely beyond the flush of scalp so that 12 days later, it was 
considered advisable to perform a bilateral decompression. 

Second Operation. — Left subtemporal decompression: usual vertical in- 
45 



7 o6 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

cision, bone removed, and no complications ; bone itself was very much thick- 
ened, spongy and vascular — being similar to the bone removed at the first 
operation. Dura thickened, whitish and moderately tense ; upon incising it, 
clear cerebrospinal fluid welled through dural opening, revealing a very 
edematous "wet" cortex but no cystic formation was exposed — only a 
whitish induration about the vessels in the sulci and a thickening of the 
arachnoid above the Sylvian fissure. At the end of the operation, the cor- 
tex bulged slightly but pulsated almost normally. Usual closure- with 2 
drains of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful recovery ; incision healed per primam. 
Within one week, there was a definite lessening of the spasticity of both legs 
and of both arms and it did seem that the child was more alert mentally 
than before. Both decompression areas bulged beyond the flush of scalp 
but pulsated normally. 

Examination at discharge (10 days after operation). — Temperature, 
98.6° ; pulse, 84; respiration, 24. Both decompression areas bulged slightly 
but with normal pulsation. Adductor spasm of both legs definitely lessened 
— possibly more in the left leg. The Achilles contracture of oach foot is still 
present owing to the very much shortened tendon — really anatomically 
short owing to the prolonged contracture over a period of years; so that the 
feet could not be flexed dorsally to a position of right angles (just as before 
the operation) . Swallowing is less difficult, however, and the speech is some- 
what more intelligible, according to the parents but our examinations do 
not confirm it. The patient is able to shake hands much more easily and 
with less awkwardness than before the operation. Pupils equal and react 
to light normally. Reflexes — patellar exaggerated, left still greater than 
right; exhaustible patellar clonus and also exhaustible right ankle clonus, 
but an inexhaustible left ankle clonus still persists ; left Babinski but right 
plantar flexion ; deep reflexes of both arms less than before the operation. 
Fundi — retinal veins enlarged; edematous blurrng of nasal margins alone 
of both optic disks; the connective tissue formation about the optic disks 
and the retinal veins naturally persists, also the pallor of each disk. 

Treatment. — On account of the double talipes equinus due to the short- 
ened Achilles tendons, a double tendon lengthening was advised upon the 
return of the child to the hospital the following week; the patient was 
accordingly removed to a! suburban home for a period of 5 days, when it 
was brought to the hospital for the operation of tendon lengthening. Upon 
the following day, the child having been prepared for the operation and 
being in a perfectly satisfactory condition, the usual administration of 
ether was begun and the child was just entering into the second stage of ether 
narcosis when respiration suddenly ceased; all attempts toward artificial 
respiration, the use of oxygen and the pulmotor were of no avail in that the 
cyanosis continued and finally the heart ceased to beat within a period 
of 8 minutes. 

Autopsy. — Head : operative areas healed perfectly ; the bone of the vault 
was very much thickened, vascular and spongy and especially over the 
parietal areas, where it reached a thickness of one-half of an inch, and 
beneath these areas there were the definite signs of a former supracortical 



OCCURRING AT THE TIME OF BIRTH 707 

hemorrhage; the dura was very much thickened and over the right parietal 
cortex was a supracortical cystic formation which had compressed and 
atrophied the underlying cortical cells ; over the left parietal cortex, there 
was no such definite cystic formation — merely a thickening of the arachnoid 
and a whitish induration about the vessels in the sulci ; this latter condition 
was present over the cortex of both hemispheres with the exception of the 
anterior portions of both frontal lobes and the posterior portions of both 
occipital lobes. The cystic formation over the right parietal cortex produced 
a slight concavity of the cortex itself, but there was apparently no primary 
destruction of the cortical cells at the time of the hemorrhage — that is, the 
condition was one of supracortical hemorrhage and the clinical impairment 
was due to compression of the underlying cortical cells and not to a primary 
destruction of them. Ventricles were negative. Heart and lungs negative. 
Kidneys negative. The ductless glands were apparently normal in size. 

Remarks. — Although the ultimate result to be obtained in this patient 
could not be expected to be a very encouraigng one, yet it is most unfor- 
tunate that whatever improvement might have been obtained, even in a 
patient so badly impaired and at such a late age, that it was not at least 
afforded to this patient and to the parents; — it being an only child. The 
findings at autopsy, however, are most instructive in that not only was the 
diagnosis of a supracortical hemorrhage confirmed, but it was demonstrated 
that an early drainage of this supracortical hemorrhage within a short 
time after the birth of the child would not only have lessened the future 
impairment, but it might have been possible to have secured a child who 
would approximate a condition of normality. 

The cause of death could not be ascertained by the autopsy and it is 
possible that the third anesthetic within a period of one month had so 
lessened the resistance of the child that merely the anesthesia, for some reason 
yet unknown, should affect the vital centres in the medulla and thereby pro- 
duce a cessation of the respiration and finally the heart. The value for 
having a permission for autopsy signed before operations is very well 
illustrated in this patient, in that not only is the diagnosis confirmed but the 
cause of death is at least known to be due to no condition which might 
have been ascertained before the operation and therefore corrected or the 
operation avoided ; in many patients, however, the cause of death is ascer- 
tained and in this manner future patients can be spared a greater risk 
than otherwise would be possible. 

Case 188. — Chronic severe brain injury at birth associated with a supra- 
cortical hemorrhage causing a marked mental retardation ; high intracranial 
pressure. Right subtemporal decompression and drainage ; 6 months later. 
left temporal decompression and drainage. Death. Autopsy; thrombosis 
of single lateral sinus. 

No. 941.— Herbert. Six years. White. U. S. 

Admitted December 6, 1917 — 6 years after birth and injury. Polyclinic 
Hospital. Referred by Doctor O. S. Hoffman, Omaha. 

Operations. — First, January 16, 1918 — right subtemporal decompression 
and drainage. Second, May 8, 1918 — left subtemporal decompression 
and drainage. 



7 o8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

Died May, 8, 1918 — 16 hours after second operation. 

Family history negative ; two younger children living and well. 

Personal History. — First child, full term, difficult labor requiring instru- 
ments; head contused, especially the right side of forehead and over the 
right parietal eminence ; difficult to resuscitate, and it was noticed that the 
child was unusually quiet during the first two weeks and had difficulty in 
nursing ; no convulsive twitchings observed. Child was considered a normal 
baby until 4 months of age, when spasmodic momentary contractions of both 
arms occurred and later of both arms and legs; apparently no loss of con- 
sciousness until three months later, when these general convulsive seizures 
would occur four and five times each day accompanied with a rolling of the 
eyeballs and at times with involuntary urination and defecation ; this con- 
tinued until nine months of age, when they ceased for one month and then 
they returned much more frequently and of greater severity for three months 
(13 months of age) ; this convulsive condition now improved and gradually 
disappeared until the last spell, which occurred when the child was 33 
months of age, and there has been none since, although there have always 
been much restlessness and excitability since that time. A general stiffness 
of mild degree of both arms and legs was observed when the child was 8 
months of age and this spastic condition increased until 14 months of age, 
when there was a gradual lessening of it, so that at 2 years of age the 
child was able: to stand alone, and at 3 years of age he was able to walk 
with only a slight awkwardness and no marked spasticity. No attempt 
has ever been made to talk; he understands, however, simple things; 
remembers tunes well — humming them months later. Patient runs and 
plays with the greatest abandon but he cannot concentrate upon anything 
for any length of time. The usual daily treatment of massage and mental 
training but with no improvement. 

Examination upon admission (6 years after birth and injury). — Tem- 
perature, 98.6° ; pulse, 84; respiration, 26; blood-pressure, 114. Well-devel- 
oped and nourished. Head slightly larger than normal and the forehead 
tends to tower over the face, so that the eyes appear sunken and the face 
small in proportion to the rather large square head. No definite spasticity of 
the arms and legs ascertained ; no adductor or flexor contractures and the 
child walks normally upon both heels and can run normally. Marked im- 
pairment of mentality in that he notices things only momentarily and 
apparently does not recognize relatives — only his nurse. Extremely restless 
— does not remain quiet more than momentarily — jumping about, clapping 
his hands and making guttural noises but no intelligible speech. Hearing' 
negative ; otoscopic examination negative. Patient can use both hands freely 
and without any awkwardness. Pupils equal and react normally. Reflexes — 
patellar exaggerated but equal; no ankle clonus but a suggestive right 
Babinski; abdominal reflexes depressed but equal; deep reflexes of both 
arms active but equal. Fundi (Doctor J. A. Kearney) — " retinal veins 
dilated, tortuous and buried in edematous tissue in places ; general regressive 
edematous changes throughout the disks; nasal halves of both optic disks 
blurred by edema ; the entire surface of the fundi around the disks pre- 
sents a finely pepper-shaken appearance; in the equatorial region there is 



OCCURRING AT THE TIME OF BIRTH 



709 



an irregular distribution of pigment in which the colloidal circulation may 
be seen in places." Lumbar puncture — clear cerebrospinal fluid under 
high intracranial pressure (30 mm.) ; Wassermann test negative and cell 
count was 4 cells per c.mm. X-ray (Doctor G. W. Welton) — ' ' convolutional 
markings typical of an increased intracranial pressure; this convolutional 
pressure atrophy of the vault has greatly thinned the bone" (Fig. 210 J. 
Head measurements! — hat circumference, 20y 2 inches; nasion-occipital pro- 
tuberance, 13 inches; intermeatal, 15 inches. 

Treatment. — It was most surprising to ascertain such an extremely 
high intracranial pressure and for fear that an error of technic had 
occurred, a lumbar puncture with a measurement of the pressure of the 
cerebros pinal fluid by 
means of the spinal mer- 
curial manometer was again 
made one week later, and 
the pressure registered a 
height of 26 mm. ; a third 
measurement of the pres- 
sure of the cerebrospinal 
fluid was taken one week 
later and a registration of 
a pressure of 24 mm. was 
obtained. (At each lum- 
bar puncture, 6-8 c.c. of 
cerebral fluid were removed 
and this drainage possibly 
accounted for the slight 
lessening of the pressure ; 
no anesthetic or local 
anesthesia was necessary 
for the puncture and the 
child remained perfectly 
quiet and relaxed at each 
puncture.) On account of this high intracranial pressure, as indicated by 
the lumbar punctures and by the ophthalmoscopic examinations, it was con- 
sidered advisable to perform a right subtemporal decompression in the 
belief that a lowering of this increased intracranial pressure would afford 
this patient a definite mental improvement and the greatest ultimate recov- 
ery possible, as it was realized that a marked improvement of the condition 
of this child could not occur in the presence of such a high intracranial 
pressure, and that later even a greater impairment would result from the 
prolonged cerebral compression. 

First Operation. — Right subtemporal decompression and drainage: usual 
vertical incision, bone removed, and no complications; the bone itself was 
unusually thin — in places being less than 1/16 and even 1 32 of an inch, 
almost like tissue paper (and due undoubtedly to the prolonged intracranial 
pressure). Dura thickened, whitish and very tense; upon incising it. clear 
cerebrospinal fluid spurted to a height of 3 inches, and upon enlarging the 




Fig. 210. — A prolonged increase of the intracranial pressure 
in a boy of 6 years of age producing pressure atrophy of the inner 
table of the vault, and chiefly in the frontal area — the so-called 
convolutional markings. 



7io DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



dural opening, the underlying edematous cortex protruded, but fortunately 
it did not rupture. (The pressure was similar to that as is frequently found 
in patients having cerebral tumors.) Above the Sylvian fissure was a 
supracortical cystic formation of almost 1 cm. in thickness, but it apparently 
extended forward toward the frontal lobe and backward to the occipital lobe 
and not upward over the motor areas of the parietal cortex. About the 
vessels in the sulci was a cloudy induration — undoubtedly due to the organ- 
ization of a former free subarachnoid 
hemorrhage. At the end of the oper- 
ation, the cortex bulged but pulsated 
slightly; much cerebrospinal fluid 
had escaped during the operation. 
The outer wall of the cystic forma- 
tion was excised and four linen 
strands inserted and brought out 
through the open dura and the tem- 
poral muscle and inserted beneath 
the scalp in a stellate manner (just 
as in similar patients having a 
condition of mild external hydro- 
cephalus secondary to a former 
supracortical hemorrhage or menin- 
gitis). Usual closure with 2 drains 
of rubber tissue inserted. Duration, 
40 minutes. 

Post-operative Notes. — Unevent- 
ful recovery ; incision healed per pri- 
mam and the patient was discharged 
on the sixteenth day after operation, 
at which time the decompression 
area bulged beyond the flush of 
scalp but pulsated slightly. 

The patient was sent to Wild- 
wood, Pa., to be under the charge of 
Doctor E. Bosworth McCready; dur- 
ing the next 5 months, a marked 
improvement occurred in that not 
only did the child become brighter mentally but the restlessness and cease- 
less movements of the hands and legs became very much less, and he 
appeared to take more interest in his surroundings and toys (Fig. 211) ; 
no real attempt, however, was made to speak. On account of the persistent 
and tense bulging and protrusion of the decompression area, it was con- 
sidered advisable to perform a left subtemporal decompression and drainage 
in order that this increased intracranial pressure might be lessened still 
more and permit a greater ultimate improvement; accordingly, the child 
was again returned to the hospital. 

Examination (5 months after operation). — Temperature, 98.6°; pulse, 
82 ; respiration, 24 ; blood-pressure, 116. Definite improvement in that the 




Fig. 211. — Definite improvement in a child of 
6 years of age following a decompressive lowering 
and drainage of the increased intracranial pressure 
resulting from a supracortical birth hemorrhage 
and a congenital absence of the right lateral sinus. 



OCCURRING AT THE TIME OF BIRTH 711 

child is much quieter than before the operation, sits in a chair or upon the 
bed playing with his toys and is in every way much more interested in his 
surroundings and in the people who enter the room ; sleeps well throughout 
the night. Pupils equal and react normally. Reflexes — patellar active but 
equal ; no ankle clonus and no Babinski can be elicited ; abdominal reflexes 
depressed but equal ; deep reflexes of both arms — present and equal. Fundi 
(Doctor J. A. Kearney) — "retinal veins dilated but not buried in edematous 
retina ; only the nasal margins of both optic disks obscured by edema ; the 
other changes persist as at the former examination. ' ' Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (16 mm.). The decom- 
pression area of the former operation bulged rather tensely beyond the 
flush of scalp and pulsated strongly. 

Treatment. — Although the high intracranial pressure had been lowered 
from that of over 24 mm., to its present height of 16 mm., yet the persistence 
of this increased intracranial pressure as registered by the spinal mercurial 
manometer, the ophthalmoscope and by the continued bulging at the site of 
the former operation, it was decided to perform a left subtemporal decom- 
pression in the hope that a normal intracranial pressure might be secured and 
therefore the greatest ultimate recovery of this patient. 

Second Operation (5 months after subtemporal decompression). — Left 
subtemporal decompression and drainage : usual vertical incision, bone re- 
moved, and no complications ; as on the right side, the bone was exceedingly 
thin, being almost like tissue paper at its lower portion. Dura thickened, 
whitish and tense ; upon incising it, clear cerebrospinal fluid welled through 
the dural opening, exposing a "wet," edematous cortex which protruded 
but did not rupture. No cystic formation observed, but about the vessels 
in the sulci was a whitish induration — the connective tissue of the organ- 
ization of a former subarachnoid and supracortical hemorrhage. Much 
cerebrospinal fluid escaped, permitting the cortex to pulsate normally at the 
end of the operation. Four linen strands, were inserted beneath the dura, 
supracortically and brought through the temporal muscle and fascia and 
inserted under the scalp in a stellate manner as a means of permanent drain- 
age. Usual closure with 2 drains of rubber tissue inserted. Duration, 
35 minutes. 

Post-operative Notes. — The child recovered from the anesthesia in good 
condition and except for an unusual amount of restlessness, nothing abnor- 
mal was noted. Twelve hours after operation, the temperature was 102°, 
pulse 88, respiration 28, and the child was sleeping quietly following the 
administration of codeine, grains 14, hypodermically ; the discharge of cere- 
brospinal fluid from the operative incision was not abnormally profuse and 
to all appearances, the condition of the child was excellent. Five hours Later 
(15 hours after operation), the child continued in the same good condition: 
30 minutes later, it was observed by the nurse that the child's face was slightly 
cyanosed although there was no cardiac or respiratory difficulty; upon sum- 
moning the house-surgeon, who arrived within 5 minutes, the face o\' the 
child had become very dark — conjunctival vessels also being dilated, and 
it was then observed that the respiration was shallow and slightly irregular ; 
an attempt at artificial respiration was made but the condition of the child 



712 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

rapidly became worse, the face becoming practically black from the extreme 
cyanosis, the respiration first ceased and then the heart stopped beating — 
4 minutes later ; that is, within a period of 15 minutes, the excellent condition 
of this patient rapidly changed to a most serious one, resulting in death — all 
within this short period of minutes. 

Autopsy. — Extreme dilatation of all the vessels of the scalp. Both 
decompression areas negative. Upon removing the vault, it was observed 
that the dural venous emissaries were all enlarged and particularly the 
longitudinal sinus, which was dilated and bulging. Upon opening the dura, 
the cortical veins were widely dilated, giving the cortex a very bluish con- 
gested appearance ; the cerebral hemispheres themselves were very edematous, 
"water-logged" and their venous channels all dilated. It was now ascer- 
tained that a left lateral sinus did not exist as the result of a congenital 
malformation and defect, and the right lateral sinus had enlarged to the 
size of one inch in diameter as compensation and in it was found a large 
thrombus almost 2 inches in length — completely occluding its lumen and 
thus being the cause for the sudden change in the child's condition. Even 
the pons and medulla were also very much congested and "water-logged" 
with edema. Over the cortex of both frontal lobes and over the right 
occipital lobe, was a cystic formation — the residue of a former supracortical 
hemorrhage ; about the cortical vessels in the sulci was a whitish connective- 
tissue formation resulting from the organization of a former subarachnoid 
hemorrhage. Ventricles negative. 

Remarks. — The importance of having obtained a permission, in writing, 
for an autopsy before the operation, is again emphasized in this most unfor- 
tunate death of a patient, for whom the greatest hopes were held of a 
marked future improvement ; not only did the autopsy findings confirm the 
diagnosis of a former supracortical hemorrhage as being the primary cause 
of the intracranial impairment and the resulting mild external hydrocephalus 
being the secondary factor in continuing this increased intracranial pres- 
sure, but they disclosed the immediate cause of the patient's death. No cause 
for the congenital absence of the left lateral sinus could be ascertained as 
it is probable that this child could have gone through life with only one 
lateral sinus with its compensatory dilatation affording a sufficient channel 
for the venous return of the intracranial blood. The sinus being on the 
right side, if a thrombus in it were to form it is thought it would occur 
more probably following the right subtemporal decompression rather than 
following the left subtemporal decompression as it did in this patient. 
Naturally, once the thrombus in this single sinus occurred, the effect of its 
presence was so overwhelming to the patient that death resulted before it 
was possible for any treatment to be of value. 

The absence of a definite cystic formation over the cortex of either 
parietal motor area explains the absence of a marked spasticity in this patient 
and the general increase of the intracranial pressure was the cause of the 
increased reflexes but not to the extent of a definite spastic paralysis. The 
presence of the hemorrhagic residue, chiefly over the frontal and the 
occipital lobes, produced the marked mental impairment associated with 
only a slight physical impairment. It is most unfortunate that this patient 



OCCURRING AT THE TIME OF BIRTH 713 

could not have been afforded the opportunity of recovery by means of an 
earl}- cranial drainage of the supracortical hemorrhage within several days 
after the child's birth and its occurrence, and in this manner the secondary 
effects of the partial blockage of the cortical veins could have been avoided 
so that there would not have developed the condition of mild external hydro- 
cephalus. A most interesting case but a most unfortunate death. 

B. Chronic brain injuries occurring in children. 

The persistent effects of brain injuries occurring in children before the 
age of ten and twelve years are very similar to those occurring in adults 
with the important exception that since the mental and emotional ' ' make-up ' ' 
of the children is in the process of development, any prolonged impairment 
of function during this formative period is later exhibited in a greater 
retarded mental and physical condition ; especially is an emotional instability 
to be feared, and if a definite cortical irritation is present to a degree that a 
mild chronic cerebral edema exists, then the danger of epileptiform seizures 
is one of not only great frequency but of the direst consequences to the 
patient ; if once convulsions occur, and especially if months and years' after 
the brain injury, then the chances of benefiting the patient are just that 
much lessened and the longer the convulsions persist the greater the improba- 
bility of any procedure being of any permanent assistance to the patient ; 
on the contrary, epileptiform seizures occurring at the time of the acute 
intracranial condition or within a short period following it — these patients 
are frequently restored to a normal mental and emotional condition by the 
appropriate medical treatment. 

The fact that children withstand the acute effects of brain injuries much 
more easily than do adults, and particularly is this true of the severe condi- 
tions of initial shock and high intracranial pressure, many children having 
brain injuries have been carelessly treated and the remote effects of the 
intracranial lesion have been overlooked — merely because the patient has 
made an immediate recovery of life ; this latter result is all-important, but the 
future normality and the good health of the child should also be considered. 
It has been recognized for a number of years that all depressed fractures of 
the vault should be elevated or removed at the time of the acute injury — not 
only for the immediate benefit to the patient but to lessen the danger of 
future impairment and complications, and especially emotional instability 
and epileptiform seizures ; this routine method of treatment has been advo- 
cated chiefly in children on account of their developmental period of life 
when an intracranial lesion, however insignificant its present symptoms and 
signs may be, yet its remote effects are frequently of a most serious char- 
acter. The significance, however, of a persistent and chronic increase of 
the intracranial pressure following brain injuries in children, whose appar- 
ent excellent recovery from the immediate effects of the injury has been 
complete, has been overlooked and it is only by examining these patients 
over a period of years that it is possible to state that these children — and 
they form less than twenty per cent, of all patients injured — do not later 
develop mentally, emotionally and physically as they should on account oi' 
the effects of a prolonged mild increase of the intracranial pressure: an 
emotional instability is possibly the most common result, a mental retarda- 



7 i4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

tion, and, as stated before, the great danger of epilepsy itself. This 
chronic cerebral edema persists in children less frequently than it does in 
adults, bnt its ultimate effects are more pronounced in children on account 
of the need for development of the cerebral nerve cells in all their activity ; 
it is thus realized that the resulting functional impairment due to an 
increased intracranial pressure, if prolonged over a period of months and \ 
years, may produce a definite organic change of tissue — and then it is 
irreparable. The treatment should be the appropriate one at the time of / 
the acute injury and not months and years later — when frequently only / 
an improvement can be obtained and not a normal individual. / 

Case 189. — Old severe brain injury associated with a fracture of t}*6 
base of the skull and with convulsive seizures; resulting mental and emo- 
tional impairment, mild secondary optic atrophy and an increased intra- 
cranial pressure. Operation advised but refused. Xo improvement. 

No. 74. — Frank. Ten years. White. U. S. 

Admitted March 22, 1914 — 15 months after injury. Polyclinic Hospital. 
Kef erred by Doctor E. W. Lawrence. 

Discharged March 28, 1914 — 6 days after admission. 

Family history negative. No nervous nor mental abnormality in the 
family of either parent; two other children well and strong. 

Personal History. — First child; nine months' pregnancy; normal labor. 
No serious children's diseases; always well and strong, and up to the time 
of the cranial injury, the boy had done well in school. 

Present Illness. — Fifteen months ago (December 6, 1912), patient was 
knocked down by a trolley-car while crossing the street ; immediate loss of 
consciousness which continued for 8 hours ; profuse bleeding from both ears ; 
taken to a hospital where he remained 10 weeks under the expectant pallia- 
tive treatment. During the first 7 days following the injury, patient had 
general convulsive seizures — as many as 8 in one day. He gradually im- 
proved, however, and yet his entire mental and emotional make-up became 
changed in that he is very quiet, sullen, refuses to speak, holds head down 
continuously, resists all attempts to move him and apparently does not 
notice anything ; is dirty in his habits and he must be fed forcibly, as other- 
wise he will remain over 24 hours without eating ; he must be dressed and 
taken care of as a child ; walks about the house or sits by himself in silence, 
holding his head down and not interested in anything. This condition has 
persisted since his discharge from the hospital — neither becoming better nor 
worse ; no complaints. No convulsions since his discharge from the hospital. 

Examination upon admission (15 months after injury). — Temperature, 
98.6°; pulse, 76; respiration, 20; blood-pressure, 110. Patient refuses to 
answer questions and pays no attention to anyone or his surroundings ; holds 
head down and his eyes have a vacant stare ; will not take candy offered 
to him nor express any emotion other than when an attempt is made to 
take his hand, he withdraws it forcibly (similar to the negativism of 
dementia praecox) . No paralyses of the extremities nor sensory impairments 
can be elicited; no ocular paralysis. Unable to test the special senses on 
account of the patient's lack of cooperation. Otoscopic examination reveals 
both tympanic membranes thickened and retracted, and a small perfor- 



OCCURRING AT THE TIME OF BIRTH 715 

ation in the lower posterior portion of the right tympanic membrane — 
the result of the former laceration at the time of the cranial injury. Pupils 
equal and react to light normally; no strabismus nor nystagmus elicited. 
Reflexes— patellar obtained with difficulty but apparently equal; no ankle 
clonus but a tendency to a left Babinski ; abdominal reflexes equally 
depressed. Fundi — retinal veins enlarged and dilated in places ; both optic 
disks rather pale from new tissue formation along the nasal margins and 
in the physiological cups w r hich are rather shallow — right optic disk more 
than left ; the nasal margins of both optic disks slightly blurred by edema. 
Lumbar puncture — clear cerebrospinal fluid under increased pressure (ap- 
proximately 13 mm.) ; ten c.c. removed for examination: Wassermann test 
was negative, and the cell count was only 4 per c.mm. X-ray (Doctor A. J. 
Quimby) — "no fracture of the skull found. " This patient was repeatedly 
examined during his residence of 6 days in the hospital and the above signs 
were confirmed ; as the patient resisted all attempts to study him with any 
degree of accuracy and refused to cooperate in any way, it was practically 
impossible to make a more thorough examination of his mental and emo- 
tional make-up. 

Treatment. — The history of the cranial injury with the definite signs of 
an increased intracranial pressure persisting for a period of months and 
producing the mild secondary optic atrophy made it advisable to suggest 
the operation of cranial decompression in the hope that it would prevent a 
greater mental and emotional impairment and possibly obtain an improve- 
ment — the operative indication being the existing intracranial pressure 
which naturally should have been relieved at the time of the injury. 
The operation was refused. The examination at discharge was the same 
as recorded above. 

Examination (September 20, 1916 — 45 months after injury and 30 
months since the last examination) . — The patient has remained in practically 
the same condition and possibly has gradually become a little worse in that 
he is even less observant than at the first examination; walks about less 
than before and must be dragged by the hand when moved; has never 
attempted to attack his brother or sister. No convulsive seizures. He resists 
all attempts to examine him as at the first examination and does not utter 
a sound. Pupils equal and react normally. Reflexes all depressed but 
otherwise negative. Fundi as at preceding examination. 

Last Examination (November 2, 1918 — 71 months after injury). — No 
change in the condition of the patient has been observed ; it is becoming so 
difficult, however, to take care of him at home that the parents are con- 
sidering the advisability of sending him to an institution and my opinion 
is to that effect, All attempts to examine him are resisted as before and 
the physical examination remains practically the same. 

Remarks. — In the absence of the histoiy of severe intracranial injury 
and the persistence of an earlier and even present increased intracranial 
pressure, the diagnosis would naturally be one of early dementia precox or 
even one of traumatic hysteria; in the presence of the history and the signs 
of an increased intracranial pressure as disclosed by the ophthalmoscopic and 
lumbar puncture findings, the more probable diagnosis is one of traumatic 



716 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

dementia following* a severe cerebral injury and most probably due to 
multiple punctate hemorrhages throughout the cerebral cortex, producing the 
marked mental and emotional impairment with its acute onset and the for- 
mation of a persistent cerebral edema, which continues to be the cause of the 
present increased intracranial pressure. If an operation with drainage of 
the acute condition had been performed at the time of the injury (as soon as 
the initial shock had been overcome), it is very possible that the condition 
of this patient would not have become so severe as at present — at least the 
ophthalmoscopic findings, and it might have been hoped that the mental 
and emotional impairment would not have become so marked. It is possible 
that this severe intracranial injury has precipitated the condition of dementia 
prgecox or at least a traumatic dementia with praecoid characteristics and this 
observation has been repeatedly made in other patients. The family history, 
however, of this patient is excellent. 

Case 190. — Chronic severe brain injury occurring at one month of age 
associated with a linear fracture of the right vault and with a mild left 
spastic hemiplegia, mild mental retardation and occasional convulsive seiz- 
ures ; an increased intracranial pressure. Right subtemporal decom- 
pression; exploratory incision of the scalp overlying a possible depressed 
fracture of the vault. Marked improvement. 

No. 970.— Mary. Three years. White. U. S. 

Admitted April 2, 1918 — 2 years and 11 months after injury. Poly- 
clinic Hospital. Referred by Doctor C. V. Niemeyer, Union Hill, N. J. 

Operation April 13, 1918. Right subtemporal decompression; explora- 
tory scalp incision. 

Discharged April 26, 1918 — 13 days after operation. 

Family history negative ; four other children living and well. 

Personal History. — Third child, full-term baby, normal labor, and no 
complications after birth; apparently a well child. When one month of 
age, child fell headlong from its carriage down an entire flight of stairs; loss 
of consciousness for fifteen minutes ; no bleeding from nose, mouth or ears 
but right side of scalp contused and boggy; it seemed that the child was 
making an excellent recovery, when on the fourth day after the cranial injury 
a convulsive seizure of the left arm, left leg and left side of face occurred, 
but apparently no loss of consciousness (a Jacksonian epileptiform convul- 
sion) ; the second convulsive seizure which became a general one occurred 
six weeks later and during: the past 35 months, the child has had a convul- 
sion always beginning in the left arm or left leg and becoming a general 
convulsive seizure every 6 to 8 weeks — the longest interval of freedom from 
convulsions ; these attacks have lasted from one to three minutes and are 
accompanied by loss of sphincteric control and an occasional biting of the 
tongue. As the child developed, it was noted that the left arm and left 
leg" were slightly more stiff and awkward than the right arm and the right 
leg ; the child, however, walked with but a slight limp of the left side. The 
general development of the child was delayed in that she did not hold her 
head up and did not attempt to crawl or to walk as early as a normal child 
should ; the speech was delayed and her present speech is slurred and indis- 
tinct; the mentality is retarded as well as the emotional reactions. 



OCCURRING AT THE TIME OF BIRTH 



717 



Examination upon admission (35 months after injury). — Temperature, 
98.6°; pulse, 84; respiration, 26; blood-pressure, 114. Well-developed and 
nourished. Mentality slightly impaired in that the child is not so alert and 
is in a sort of confused hazy condition; rather irritable; unable to speak 
plainly and only in monosyllables ; she walks with but a slight limp of the 
left leg — heel just touching the floor. Upon bimanual examination of the 
head, there is a possible depression of the right parietal bone ; no tenderness. 
Hearing negative ; otoscopic examination negative. Pupils equal and react 
to light normally. Reflexes — patellar exaggerated, left more than right ; no 
ankle clonus but suggestive left Babinski; abdominal reflexes present and 
equal ; reflexes of left arm more active than of right. Fundi — retinal veins 
enlarged; nasal margins of both optic disks blurred by edema — the other 
details being clear and dis- 
tinct. Lumbar puncture — 
clear cerebrospinal fluid 
under increased pressure 
(16 mm.) ; Wassermanntest 
negative and cell count was 
4 cells per c.mm. X-ray 
(Doctor G. W. Welton) — 
i 'wide u-shaped fracture 
•extending antero-poste- 
riorly through middle por- 
tion of right parietal bone ; 
no depressed fragments ob- 
served" (Fig. 212). 

Treatment. — On account 
of the increased intra- 
cranial pressure associated 
with convulsive seizures be- 
ginning in the left arm and 
in the left leg and with a 
mild spastic paralysis of the 

left side of the body with mental retardation, a right subtemporal decom- 
pression was advised and also an exploratory incision of the scalp overlying 
the right parietal bone — the area of a possible depressed fracture of the vault. 

Operation (almost 3 years after injury), — Right subtemporal decompres- 
sion; exploratory incision of the scalp. Usual vertical incision, bone 
removed and no complications. Dura thickened, whitish, tense and slightly 
bulging; upon incising the dura, a very "wet," edematous cortex tended to 
protrude but did not rupture owing to the escape of a large quantity of 
clear cerebrospinal fluid which at first spurted to a height of 2 inches ; upon 
enlarging the dural opening, there was exposed a cloudy, whitish connective 
tissue formation about the vessels in the sulci — the organization of a former 
supracortical subarachnoid hemorrhage (and the cause of the partial block- 
age of the excretion of the cerebrospinal fluid and thus the formation of a 
mild external hydrocephalus — the "wet," edematous condition of the cor- 
tex). No gross cortical hemorrhage or laceration observed. Brain pulsated 




Fig. 212. — Irregular linear fracture of the right vault occurring 
in a child of one month of age; a resulting supracortical hemor- 
rhage produced a left spastic hemiplegia with mental retardation 
and convulsive seizures. Marked improvement following a 
lowering of the increased intracranial pressure by means of a 
right subtemporal decompression and drainage. 



7 i8 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

normally at the end of the operation. Usual closure with 2 drains of rubber 
tissue inserted. Duration, 30 minutes. A small curvilinear scalp incision 
was now made higher up over the right parietal bone and the possible 
depressed fracture; upon retracting the scalp, the large linear fracture, 
having a width of almost one-half inch, was found pulsating; no depres- 
sion. It was considered better surgical judgment not to attempt an explora- 
tion of this area in the hope that the subtemporal decompression would be 
sufficient to obtain an excellent result. Usual closure. Duration, 65 minutes. 

Post-operative Notes. — Uneventful convalescence in that incisions healed 
per primam; decompression area bulged, but pulsated normally ; within one 
week, it was observed that, the slight stiffness of the left arm and left leg 
had definitely lessened. 

Examination at discharge (13 days after operation). — Temperature. 
98.8° ; pulse, 82; respiration, 24; blood-pressure, 112. Decompression area 
bulges slightly and pulsates normally ; both scalp incisions have healed per- 
fectly. Stiffness and awkwardness of left side of body definitely less than 
before the operation ; child is possibly more interested in her surroundings. 
Pupils equal and of normal reaction to light. Reflexes : patellar — left more 
active than right; no ankle clonus and suggestive left Babinski persists; 
abdominal reflexes present and equal ; reflexes of left arm less active than 
before the operation. Fundi — retinal veins slightly enlarged; edematous 
blurring of nasal margins of both optic disks less marked. 

Treatment. — Continued as before the operation in that the diet is re- 
stricted by the avoidance of all meats, meat soups, tea and coffee; daily 
movement of the bowels ; daily massage and exercises continued. 

Last Examination (June 20, 1919 — 14 months after operation). — No 
convulsive seizures have occurred since the operation ; a marked improvement 
has occurred in the lessening of the stiffness and awkwardness of the left arm 
and the left leg, so that now no impairment can be noted — child walks like a 
normal child ; speech has improved, although there is still a slight hesitancy 
and slurring of words ; both mentally and emotionally the improvement is 
marked. Reflexes : patellar — left slightly more active than right ; no ankle 
clonus and no Babinski ; reflexes of left arm slightly increased over those 
of right. Fundi — retinal veins of normal size ; no edematous obscuration 
of the details of either optic disk. Decompression area depressed and 
pulsates normally ; some new bone formation at the periphery slightly nar- 
rows the bony opening. 

Remarks. — The cranial injury of this patient occurring 4 weeks after 
birth can be considered almost as being a birth injury and the resulting 
impairment of this patient, both mentally and physically and associated with 
convulsive seizures, is so characteristic of patients having an intracranial 
hemorrhage at the time of birth, that this patient may be classed with them. 
The absence of a depressed fracture of the right vault but the presence of 
an increased intracranial pressure associated with convulsive seizures and 
a mild spastic paralysis of the left side indicated the condition of a supra- 
cortical hemorrhage of the right cerebral hemisphere and this was con- 
firmed at operation. 

It is unfortunate that this child could not have been operated upon at the 



OCCURRING AT THE TIME OF BIRTH 719 

time of the cranial injury and as soon as the signs of shock had disappeared, 
and in this manner not only would the mental and physical impairments have 
been avoided but the convulsive seizures have probably been prevented, for 
this early operation would have drained the blood in fluid form so that 
the secondary blockage of the cerebrospinal fluid would not have followed 
later to the extent that it did; although the improvement of this patient 
has been a most gratifying one following this late operation, yet it will 
be necessary to wait a period of years before it can be definitely stated that 
the recovery of the child, and especially from the convulsive seizures, is a 
permanent one and that this patient will become, or at least approximate, 
a normal person, both mentally and emotionally. The partial blockage of 
the. cerebrospinal fluid naturally is a permanent one, but it is hoped that 
the operation of decompression will afford sufficient drainage to permit the 
amount of intradural cerebrospinal fluid to remain normal; in those 
patients where the blockage is even greater, then it is advisable to insert 
the linen strands for drainage subdurally just as in the cases of severe 
external hydrocephalus. 

The rapid improvement of the physical condition of this patient and 
also of the mental retardation, including the difficulty of speech, is very im- 
pressive and merely confirms the belief that these impairments are merely 
functional to the extent that there is not a primary destruction of cerebral 
tissue, but that the impairments result from an increased intracranial pres- 
sure due to the partial blockage of the excretion of the cerebrospinal fluid 
and producing therefore a "wet," edematous condition of the cerebral 
cortex under varying degrees of pressure — a mild condition of external 
hydrocephalus ; the therapeutic indication therefore is to lessen this in- 
creased intracranial pressure, either by the use of the thyroid extract in the 
very mild conditions by decreasing the amount of cerebrospinal fluid secreted, 
or by the operative and mechanical lowering of the higher degrees of 
increased intracranial pressure by means of the subtemporal decompression 
and drainage; naturally, the earlier this lessening of the increased intra- 
cranial pressure is possible, just so much greater is the improvement and the 
avoidance of later mental and physical impairments. 

Case 191. — Old severe brain injury associated with a depressed fracture 
of the left parietal vault and with signs of increased intracranial pressure ; 
right hemiplegia and attacks of petit mat. Left subtemporal decompres- 
sion and drainage. Improvement. 

No. 38.— Albert. Twelve years. White. School. U. S. 

Admitted October 20, 1913 — 5 years after injury. Polyclinic Hospital. 
Referred by Doctor 0. S. Wightman. 

Operation October 27, 1913. Left subtemporal decompression. 

Discharged November 8, 1913 — 11 days after operation. 

Family history negative; 2 older brothers and one younger sister well 
and strong; parents normal and of temperate habits; no miscarriages. 
Parents and relatives all right-handed. 

Present History. — Patient is third child ; full term baby, normal labor 
and no abnormalities observed after birth. Patient was considered a normal 
child until the cranial injury at 7 years of age. Five years ago. patient 



7 2o DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



fell from a second-story window, striking upon the left side of his head; 
immediate loss of consciousness and bleeding" from the left ear ; taken to a 
hospital where the depressed area of the left parietal bone was elevated; 
patient remained unconscious for 5 days and unable to speak during the 2 
weeks following the injury ; definite weakness of entire right side of body so 
that at discharge, 4 weeks after injury, he was described as having ''right 
spastic hemiplegia." Patient slightly improved during the first year after 
his discharge from the hospital, but no improvement has occurred during 
the past 4 years. Xo headache nor other complaints except the right spastic 

hemiplegia, a mental retarda- 
tion and an emotional insta- 
bility; during the past 2 
months, patient has had 
several momentary losses 
of consciousness — s taring 
blankly and dropping what- 
t ever was in his hand; no 

convulsions, however, at any 
time. 

Examination upon admis- 
sion (5 years after injury). 
—Temperature, 98.6° ; pulse, 
84; respiration, 24; blood- 
pressure, 120. Well-devel- 
oped and nourished. Over 
the left parietal region was 
a depressed area of bone as 
though some of the underly- 
ing bone had been removed 
at the former operation. 
Typical right spastic hemi- 
plegia with the characteristic 
flexion of the right arm and 
position of the right leg due 
to the flexor contraction of 
the right foot, so that patient 
walked upon the toes of the right foot on account of the contraction of the 
Achilles tendon. Definite slurring of speech but no aphasia nor paraphasia. 
No sensory impairment. Pupils equal and react normally. Reflexes : patel- 
lar — right much more active than left ; no ankle clonus but right Babinski ; 
abdominal reflexes — right depressed. Fundi — retinal veins dilated and their 
walls thickened with new tissue formation; nasal margins of both optic 
disks obscured and much new tissue formation about the margins and in the 
physiological cups. No lumbar puncture performed; Wassermann test of 
blood, however, was negative. X-ray (Doctor A. J. Quimby) — "irregular 
bony defect of 2 cm. in diameter in left parietal area ; slight depression at 
its periphery; no linear fracture ascertained" (Fig. 213). 




Fig. 213. — -Posterior view of an irregular bony defect and new 
bone formation over the left vault in a boy of 12 years of age 
following a cranial injury five years before; the right spastic 
hemiplegia and epileptiform spells improved by lowering the 
increased intracranial pressure by means of a left subtemporal 
decompression and drainage. 



OCCURRING AT THE TIME OF BIRTH 721 

Treatment. — The presence of an increased intracranial pressure as 
revealed by the ophthalmoscopic examination, together with the definite right 
hemiplegia, made a left subtemporal decompression advisable in the hope 
that a lessening of this increased intracranial pressure would result in a 
lessened spasticity of the right arm and right leg, an improvement of the 
mentality made possible and the emotional instability improved. 

Operation (5 years after injury). — Left subtemporal decompression: 
usual vertical incision, bone removed, and no complications ; at upper por- 
tion of operative area, the bone was depressed and upon removing it, the 
underlying dura was found torn or incised at the former operation, and 
it was therefore thought advisable to remove only the lower portion of the 
overlying bone. The dura of the decompression area was now incised as 
usual, allowing clear cerebrospinal fluid to spurt under tension; upon 
enlarging the dural opening, the underlying cerebral cortex tended to pro- 
trude but did not rupture ; bluish cystic formation beneath the arachnoid and 
above the Sylvian fissure ; this was punctured, allowing straw-colored cere- 
brospinal fluid to escape. Owing to the escape of cerebrospinal fluid, the 
cortex became relaxed and pulsated normally. Usual closure with 2 drains 
of rubber tissue inserted. Duration, 40 minutes. 

Post-operative Notes. — Uneventful operative recovery, cranial in- 
cision healed per primam, so that patient could be discharged 11 days 
after operation. 

Examination (September 6, 1914 — 10 months after operation). — Patient 
has made a definite improvement in that the spasticity of the right arm and 
of the right leg has lessened, and although he still limps, yet the right heel 
touches the floor and the lameness is not so marked ; patient can use the right 
hand for simple duties (Fig. 214). Teacher in school says that he can now 
be taught more easily and is much more interested in things; also not 
so irritable. Mother says that no ' ' fainting ' ' spells have occurred since the 
operation. Decompression area slightly depressed and pulsates normally. 
Reflexes: patellar — right more active than left; no ankle clonus but right 
Babinski; right abdominal reflexes less active than left. Fundi — retinal 
veins slightly enlarged ; nasal margins of optic disks no longer blurred by 
edema but new tissue formation naturally persists. 

Examination (October 12, 1916 — 36 months after operation). — Patient 
has continued to improve both mentally and physically; the right spastic 
hemiplegia., however, is still present but much lessened in severity, so that 
patient now walks with but a slight limp ; the condition of the right arm has 
improved but not so much as the right leg. Patient has advanced in school. 
No attacks of petit mal have occurred. Reflexes : patellar — right greater than 
left; no ankle clonus but right Babinski persists; right abdominal reflexes 
depressed. Fundi — retinal veins slightly larger than normal: optic disks 
clear but new tissue formation is present. Decompression area depressed and 
slight pulsation palpable. 

Last Examination (November 6, 1918 — 60 months after operation). — 
Patient is practically the same as at preceding examination ; the right hemi- 
plegia is present but only in a modified degree compared with the condition 
before operation and the patient is mentally and emotionally more normal. 
46 



722 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



i 



i 



7; 



l! 



1 



I 



L. 



Fig. 214. — Ten months following a left subtemporal decompression and drainage for the lowering of 
the increased intracranial pressure due to a supracortical hemorrhage at the time of the former cranial 
injury in a boy of 12 years of age, having the condition of right spastic paralysis. Marked improvement. 



OCCURRING AT THE TIME OF BIRTH 723 

No signs of petit mat attacks. Decompression area markedly depressed and 
its diameter is lessened due to new bone formation at the jjeriphery . 
Reflexes: patellar — right more active than left; no ankle clonus but right 
Babinski; abdominal reflexes — right less than left. Fundi as at preced- 
ing examination. 

Remarks. — The condition of this patient resembles so closely and in such 
detail the condition of those children having cerebral spastic paralysis due 
to an intracranial hemorrhage at the time of birth — due usually to a difficult 
labor ; in this case, however, we have a child who was normal until the age 
of 7 years, when the cranial injury occurred ; it would seem that a subtem- 
poral decompression and drainage should have been performed at the time 
of the injury and not merely the elevation of the depressed area of bone 
performed; undoubtedly, there has been some destruction of the cortical 
nerve cells supplying the right arm and the right leg and naturally a com- 
plete recovery therefore cannot be expected. It is encouraging, however, 
that during a period of 5 years following the decompression operation, no 
spells of petit mal character have appeared again and it is to be hoped 
that the lessening of the increased intracranial pressure will prevent this 
frightful complication from occurring. It will be very interesting to watch 
this patient over a number of years — not so much what his present condi- 
tion is, but what his future condition will be 15 to 20 years from now, when 
he will begin to assume the duties of manhood. 

Case 192. — Chronic severe brain injury associated with a depressed 
fracture of the vault of the skull and with a resulting hemiplegia and mental 
retardation; an increase of the intracranial pressure. Left subtemporal 
decompression and then a removal of the depressed area of bone. 
Marked improvement. 

No. 791.— John. Ten years. White. School. U. S. 

Admitted February 20, 1917 — 3 years after injury. Polyclinic Hospital. 
Referred by Doctor John A. Wyeth. 

Operations. — First, February 28, 1917 : left subtemporal decompression. 
Second, March 7, 1917 — 7 days after the first operation: removal of de- 
pressed area of vault. 

Discharged March 16, 1917 — 9 days after second operation. 

Family history negative. 

Personal History. — Third child, full term, normal labor, and no compli- 
cations. Child was considered a normal one in every way until he was 
seven years of age (3 years ago), when he fell from a ladder, striking upon 
the left side of his head; immediate loss of consciousness and was taken 
in the ambulance to St. Vincent's Hospital, where he remained three months ; 
there was a paralysis of the right arm and right leg observed upon the day 
following the injury when a right-sided convulsion occurred. As the con- 
dition of paralysis slightly improved and as no other convulsive seizure^ 
occurred, no operation was performed, and at the end of three months the 
patient was discharged from the hospital. Since then, there has remained a 
definite spastic paralysis of the right arm and of the right leg and the 
patient has been unable to advance in school more than one class dining the 
past 3 years; frequent severe headaches have been complained oi' by the 



7 2 4 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

patient and the emotional irritability lias increased; no convulsions since 
the day following the injury. 

Examination upon admission (3 years after injury). — Temperature, 
98.6° ; pulse, 78 ; respiration, 24 ; blood-pressure, 114. Patient is rather dull 
and non-observant; apparently not interested in his surroundings and 
answers questions in a slow hazy manner ; very irritable upon being chided. 
Marked spastic paralysis of the right hemiplegia type — the right leg being 
possibly affected more than the right arm ; the lower right side of the face is 
also impaired (the cortical type of right facial paralysis). Upon local 
bimanual examination, there is a definite depressed fracture of the left 
parietal bone almost 3 inches long, one-half inch wide and easily one-fourth 
of an inch in depth, extending horizontally about one and a half inches to 
the left of the longitudinal sinus ; not tender. Hearing negative, apparently, 
although it is difficult to rely upon the patient 's answers as he seems rather 
confused ; otoscopic examination, however, negative. Pupils equal and react 
normally to light. Reflexes — patellar active, right much more than left; 
right patellar and right ankle clonus; right Babinski, Oppenheim and 
Gordon reflexes ; abdominal reflexes — right depressed and very difficult to 
elicit. Pupils — retinal veins enlarged with thickened walls; both optic 
disks slightly pale from new tissue formation about the nasal margins and 
in the physiological cups — the left possibly more than the right optic disk ; 
nasal margins of both optic disks blurred by edema. Lumbar puncture — 
clear cerebrospinal fluid under increased pressure (14 mm.) . X-ray (Doctor 
W. H. Stewart) — "no evidence of a displaced section of the left vault." 

Treatment. — The history of the cranial injury with the resulting right 
spastic hemiplegia and the present findings of a definite increase of the 
intracranial pressure and the depressed fracture of the left vault (not 
confirmed by the rontgenogram) with the right spastic hemiplegia persisting 
and a marked mental retardation and emotional instability — these facts 
made the operation of left subtemporal decompression advisable and then 
the elevation or removal of the depressed area of the left parietal bone, if 
found as indicated by the bimanual examination. 

First Operation (3 years after injury): — Left subtemporal decompres- 
sion : usual vertical incision, bone removed, and no complications. Dura 
moderately tense, thickened and vascular; upon incising it, much clear 
cerebrospinal fluid welled out, and upon enlarging the dural opening the 
underlying edematous cortex tended to protrude but did not rupture, owing 
to the rapid escape of the cerebrospinal fluid. At the upper portion of the 
operative field and above the Sylvian fissure was exposed a film of a fibrous 
cystic formation — the result of a former supracortical hemorrhage which 
had extended from above downward over the parietal area of the cortex. 
About the cortical vessels in the sulci in this same area was a whitish indura- 
tion — the organization of the former free blood about the vessels in the 
sulci. The overlying arachnoid was punctured with a needle in several 
places, allowing a straw-colored fluid to escape and the cystic formation to 
collapse. At the end of the operation the cortex pulsated normally. LTsual 
closure with 2 drains of rubber tissue inserted. Duration, 35 minutes. 

Post-operative Notes. — No complications; operative incision healed per 



OCCURRING AT THE TIME OF BIRTH 725 

primam, while the operative area itself bulges beyond the flush of scalp 
but pulsates normally. An attempt was now made to remove the depressed 
area of the vault. 

Second Operation (7 days after first operation). — Removal of depressed 
area of vault : curvilinear incision over the depressed area of the left parie- 
tal bone of 3 inches in length; upon retraction of the scalp, it was found 
that there was a longitudinal depressed fracture of the left parietal bone 
about 2 inches in length, one-half inch in width and almost one-half inch 
in depth. It was possible to insert the rongeurs at the edge of the bony 
depression, so that the bony opening 1 could be enlarged and the depressed 
fragment of bone was removed. The underlying dura was not torn and it 
was considered advisable and better surgical judgment not to open it as the 
left subtemporal decompression had lowered the increased intracranial 
pressure and it was now too late to remove the supracortical hemorrhage, 
since it had become organized and only a lowering of the intracranial pres- 
sure and the removal of the bony local compression were considered 
necessary. Usual closure with 2 drains of rubber tissue inserted down 
the dura. Duration, 25 minutes. 

Post-operative Notes. — Uneventful operative recovery; incision healed 
per primam; within 5 days, patient no longer complained of the dull head- 
ache and said his head "felt lighter." Decompression area bulged but 
pulsated normally. 

Examination at discharge (9 days after second operation). — Tempera- 
ture, 98.6° ; pulse, 82; respiration, 24; blood-pressure, 116. Patient appears 
somewhat brighter in that he is more interested in his surroundings ; no 
complaints other than a soreness of left side of head. Decompression area 
bulges beyond the flush of scalp ; pulsation normal. Right arm and right leg 
possibly not so spastic as before the operation ; the patient walks with less 
of a limp ; is using the right hand possibly better. Pupils negative. Re- 
flexes : patellar — right more active than left ; exhaustible right patellar 
clonus and right ankle clonus ; right Gordon, Oppenheim and Babinski 
reflexes persist; right abdominal reflex less active than left. Fundi— 
retinal veins enlarged ; no change from former f undal examination unless the 
nasal margins of the optic disks are not so obscured by edema as before the 
operation. Another rontgenogram taken, showing the bony defect of remov- 
ing the depressed area of bone (posterior view) (Fig. 215). 

Treatment. — Parents were advised the usual hygienic rules, a non- 
proteid diet and the avoidance of school until the next fall. 

Examination (April 20, 1918 — 13 months after operation). — Child has 
made a marked improvement during the past year in that the spasticity of the 
right arm and leg has so lessened that the patient can walk much more 
freely and can use the right arm less awkwardly than before the operation ; 
the right side of face is still slightly weak and lags in its movements. The 
mentality has also improved and he is able to study and enjoy it ; no 
longer complains of headaches and has had only "two attacks of temper" 
during the past 6 months. The decompression area extends beyond the 
flush of the surrounding scalp but pulsates normally. Pupils equal and 
react to light normally. Reflexes: patellar — right more active than left: 



726 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



no right patellar clonus but an exhaustible right ankle clonus ; right 
Babinski still persists but neither an Oppenheim or Gordon reflex can be 
elicited; right abdominal reflexes depressed. Fundi — retinal veins slightly 
larger than normally; both optic disks rather pale from connective tissue 
formation as before the operation, but there is no edematous obscuration of 
the nasal margins. Visual acuity : 16/20 in the left eye and 18/20 in the 
right eye — the result of a mild secondary optic atrophy; no limitation of 
the visual fields ascertained. 

Last Examination (May 14, 1919 — 26 months after operation). — The 
improvement has continued during the past year so that the right side of 
the body can be used with less awkwardness than before and the mentality 

of the patient has become 
much brighter, more alert 
and his emotional reac- 
tions are more stable; 
right facial paresis per- 
sists but is hardly notice- 
able (Fig. 221) ; he has 
advanced with his class in 
school, although he is still 
2 years behind his regular 
class. No complaints of 
headache or convulsive 
seizures. Decompression 
area bulges beyond the 
flush of the scalp. Re- 
flexes : patellar — r i g h t 
greater than left; slight 
exhaustible right ankle 
clonus persists and right 
Babinski ; right abdominal 
reflexes less active than 
left. Fundi — the same as 
at preceding examination. 
Visual acuity remains 
practically the same as at the preceding examination one year ago. 

Treatment. — The massage, daily exercises and his mental train- 
ing are advised to be continued as before, together with the routine 
hygienic measures. 

Remarks. — The similarity of these patients having depressed fractures 
of the vault of the skull and with a resulting increase of the intracranial 
pressure to those patients having a spastic paralysis with mental retardation 
and emotional instability as the result of an intracranial hemorrhage at 
the time of birth with a resulting increased intracranial pressure — this simi- 
larity is very great indeed and in reality the condition is the same, except 
that in the patients having an increased intracranial pressure resulting 
from an intracranial hemorrhage at birth, the results of the condition are 
usually more pronounced because the increased intracranial pressure 




Fig. 215. — Irregular bony defect of left vault following the 
removal of depressed bone in a boy having the condition of right 
spastic hemiplegia with mental retardation. Marked improvement 
following the operation and the lowering of the increased intra- 
cranial pressure by means of a left subtemporal decompression 
and drainage. 



OCCURRING AT THE TIME OF BIRTH 



727 



occurred during the earliest stage of mental and emotional development, 
and therefore not only is the retardation greater but it is a much more 
serious and permanent one; the normal development of the cortical cells 
is prevented and therefore the mental and physical impairment is more 
pronounced than that which follows an intracranial hemorrhage of similar 
degree occurring in a child who has already developed mentally and physi- 
cally as is normal for the age at which the intracranial hemorrhage occurred. 
Merely because a depressed fracture of the vault is not present in only a 
very small percentage of children having an intracranial hemorrhage at the 
time of birth — this is no reason to consider these patients as being essentially 
different pathologically and clinically from the ones showing external 
evidence of cranial injury, such as a depressed fracture of the skull; the 
important factor to ascertain is the presence or not of an increased intra- 
cranial pressure due to intracranial hemorrhage or persistent cerebral 
edema, and if found to be present, then an operation of decompression and 
drainage should be performed to lower it — 
whether there is a depressed fracture of the 
skull or not; in this manner, the mental 
and physical impairment and retardation 
cannot only be improved but — more im- 
portant — be prevented if the operation is 
performed early. Naturally, all depressed 
fractures of the vault should be elevated 
or removed for fear of future complica- 
tions such as epilepsy ; the danger of con- 
vulsive seizures occurring later in this 
patient was very great indeed and they 
are still to be feared even with the appa- 
rent success of the operations performed. 

On account of the increased intra- 
cranial pressure, it was better surgical 
judgment to lower this pressure first by 
means of the subtemporal decompres- 
sion performed on the same side as the depressed area of the vault, and 
then it was possible to remove the depressed area of the vault safely and with 
no risk to the underlying cerebral cortex ; to have opened the cerebral cortex 
underlying the depressed area of the vault in this patient and a decom- 
pression not having been previously performed, would have been of great 
danger to the patient as the more highly developed areas of this underlying 
cortex would have become damaged by their protrusion owing to the high 
intradural pressure and, in this manner, the end-result could not have been 
so successful as when the decompression is performed first rather than after 
the local operation upon the depressed area of the vault. 

The supracortical pathology as ascertained at this operation is very typi- 
cal of the condition as found in practically all of the patients having a spastic 
paralysis resulting from an intracranial hemorrhage at the time of birth: 
that is, a supracortical fibrous and cystic formation occurs as the result of 
the non-absorption of the free subdural and subarachnoid hemorrhagic clot 




Fig. 216. — The area of the left decom- 
pression bulges so markedly that there can 
be no doubt as to the increased intracranial 
pressure in this patient and the necessity 
of lessening it in order to obtain an im- 
provement. The right facial weakness is 
much less than before the operation. 



728 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

and the connective tissue formation as the result of the organization of the 
free blood about the vessels in the sulci ; in this latter manner, the stomata of 
exit for the normal excretion of the cerebrospinal fluid through the walls of 
the cortical veins in the sulci are partially blocked and therefore a mild 
"wet," edematous condition of the brain results — a mild secondary exter- 
nal hydrocephalus. 

Case 194. — Chronic severe brain injury associated with a fracture of the 
vault of the skull ; apparently an excellent recovery until the later develop- 
ment of an internal hydrocephalus and the signs of a tumor of the right half 
of the cerebellum — most probably a tuberculoma. Right subtemporal decom- 
pression and permanent ventricular drainage. Marked improvement. 

No. 1081.— Elmer. Nine years. White. School. U. S. 

Admitted July 22, 1919 — 9 months after cranial injury. Audubon 
Hospital. Referred by Doctor E. B. McCready, Pittsburgh. 

Operation July 30, 1919. Right subtemporal decompression and ven- 
tricular drainage. 

Discharged August 6, 1919 — 7 days after operation. 

Family History. — Father died from "pneumonia" three years ago: 
mother living and well ; three brothers living and well. 

Personal History. — Third child, full term, normal labor. Usual child- 
hood diseases and apparently in the best of health during the two years 
preceding the cranial injury. Nine months ago (November 6, 1918), while 
the patient was playing in the street, he was knocked down by an automo- 
bile ; immediate loss of consciousness with profuse bleeding from the left 
ear; he was taken to a hospital — remaining unconscious for 2 days and 
finally recovered so that he could be discharged at the end of 2 weeks ; ( an 
X-ray picture taken at that time disclosed a ' ' linear fracture of the left half 
of the occipital bone and extending forward toward the left auditory canal"). 
Patient apparently made an excellent recovery and within one month he 
appeared to be perfectly well. Two weeks later, however (iy 2 months 
ago) , patient began to complain of dull frontal and occipital headaches, early 
fatigue and a general weakness; within 2 weeks, he began to stagger in 
walking, tending to fall toward the right side and also backward; attacks 
of vomiting now occurred irrespective of eating. One month later, it was 
noticed that the child was unable to see as clearly as formerly so that his 
school teacher had his seat placed at the head of the class; the headaches 
continued, the difficulty of standing and of walking became greater until 3 
months ago, the child was unable to walk or to stand alone owing to his stag- 
gering and falling to the right and backward. The impairment of vision in- 
creased until he could not distinguish fingers or large objects with his left eye 
and only with difficulty with his right eye. His condition had been diagnosed 
as an irreparable brain injury due to the cranial injury at the time of the 
accident — a destruction of cerebral tissue and therefore a hopeless condition. 

Examination upon admission (9 months after injury). — Temperature, 
98.6°; pulse, 82; respiration, 26. Well-developed and nourished; rather 
drowsy and confused mentally. Patient complains of severe frontal head- 
ache and inability to see. Head larger than the average, although within 
physiological limits ; upon palpation, a definite linear fracture of the left half 






OCCURRING AT THE TIME OF BIRTH 



72c, 




of the occipital bone extends forward into the left mastoid area ; a possible 
depression of the bone just posterior to the left mastoid area. Hearing of 
left ear markedly impaired ; bone conduction greater than air conduction ; 
otoscopic examination discloses a small perforation in the lower posterior 
half of the left tympanic membrane which is whitish, thickened and retracted. 
Patient is blind in the left eye and can only distinguish light with it, whereas 
with the right eye he can count fingers and distinguish large objects but with 
great difficulty. Coarse nystagmoid twitches toward the right but none 
toward the left. No weakness of the ocular muscles. Definite weakness 
of the right side of face in its entire distribution (the peripheral type of 
facial paralysis). No impairment of hearing of the right ear. No impair- 
ment of sensation of the right side of the face. The right arm and the right 
leg are slightly weaker than , ^^ 

the left arm and left leg. 
Distinct intention tremor of 
both hands, especially the 
right hand in the pointing 
tests. No definite speech de- 
fect or slurring of words ; no 
impairment of swallowing. 
Typical Romberg in that the 
patient always falls to the 
right and backward; in at- 
tempting to walk, he stag- 
gers to the right dragging 
the right leg. Pupils: 
slightly enlarged but equal; 
sluggish reaction to light. 
Reflexes — p a t e 1 1 a r very 
much exaggerated but equal ; 
no ankle clonus; bilateral 
Babinski ; abdominal reflexes 
absent. Fundi — retinal veins dilated, tortuous and buried in places in 
edematous tissue; double "choked disks" of 5 diopters of swelling and 
much new tissue formation so that it is assuming a whitish appearance 
of a progressive secondary optic atrophy; this latter condition is more 
advanced in the left eye. X-ray (Doctor A. J. Quimby) — "wide linear 
fracture of the left vault posteriorly extending downward to left mas- 
toid area" (Fig. 217). Lumbar puncture — clear cerebrospinal fluid under 
high pressure (38 mm.) ; Wassermann test negative and cell count was 
14 cells per c.mm. (Only 2 c.c. of the cerebrospinal fluid were removed 
and very carefully, for fear that medullary complications might be in- 
duced. ) Tuberculin skin test negative. 

Treatment. — The presence of the signs of very high intracranial pressure 
sufficient to produce a secondary optic atrophy would indicate a severe degree 
of internal hydrocephalus due to a subtentorial or posterior basal lesion 
or to a very large cerebral tumor, and since the secondary optic atrophy 
had advanced more in the left eye, the greater possibility of a tumor of the 




Fig. 217. — Extensive linear fracture of the posterior por- 
tion of the left vault in a boy developing later an internal hydro- 
cephalus due most probably to a subtentorial tuberculoma. 
Marked improvement following a right subtemporal decompres- 
sion and permanent ventricular drainage. The pressure atrophy 
of the vault and the convolutional pressure markings are more 
noticeable in the frontal area. 



730 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

left cerebral hemisphere. The clinical signs, however, would indicate a 
lesion of the right half of the cerebellum — the homolateral weakness of the 
right arm and right leg, the intention tremor more marked in the right 
hand, the coarse nystagmus to the right and the right facial paresis of 
peripheral type (this last sign being more indicative of a right cerebello- 
pontine angle tumor, but the absence of an impairment of hearing of the 
right ear or of sensation of the right side of the face would tend to exclude 
this localization). The history of the cranial injury and the resulting 
fracture of the posterior vault of the skull is very interesting ; possibly this 
injury lessened the resistance of the underlying cerebellar tissue by contu- 
sion, etc., so that the formation of a tuberculoma in them was facilitated — 
just as injuries to the joints of the body render them more susceptible to 
disease and especially to tuberculosis ; the injury, however, may have occurred 
after the intracranial lesion had been in existence for some time and the 
injury itself merely precipitated its progress. It was considered advisable to 
perform first a right subtemporal decompression and at the same time estab- 
lish permanent ventricular drainage in the belief that the lesion was a tuber- 
culous one and if the effects of its presence, and particularly the blockage of 
the ventricles, could be obviated, then it would not be necessary (nor is it 
advisable) to attempt a removal of the growth itself; besides, the risk of this 
operative procedure of subtemporal decompression and ventricular drain- 
age is a slight one. 

Operation (9 months after cranial injury). — Right subtemporal decom- 
pression and ventricular drainage : usual vertical incision, bone removed, 
and no complications ; the bone itself was so thin, as a result of a prolonged 
increase of the intracranial pressure, that it was of a thickness of not more 
than a sheet of paper — so thin that it could be depressed by digital com- 
pression similar to a "ping-pong" depression. Dura under high tension, 
bulging into bony opening and similar to a drum in tightness; its vessels 
had been entirely compressed and obliterated by the prolonged tension; 
upon making a small opening in it, no cerebrospinal fluid escaped, and it 
was considered better judgment to attempt a ventricular puncture and 
removal of ventricular cerebrospinal fluid before enlarging the dural open- 
ing for fear of the underhung cerebral cortex being ruptured by the high 
tension. Ventricle puncture needle was inserted to a depth of 2 cm. when 
clear cerebrospinal fluid spurted through the needle to a height of 5 inches ; 
a large quantity of it escaped, permitting the dural tension to lessen and the 
cortex to pulsate almost normally. Six linen strands were inserted into 
the ventricle and permitted to extend through the temporal muscle and 
fascia outward into the subcutaneous tissues of the scalp in a stellate manner, 
and as a means of permanent drainage of the ventricles, just as in condi- 
tions of internal hydrocephalus in children. The dural opening was now 
enlarged as in the usual decompression operation and as the cortex pul- 
sated normally owing to the escape of so much ventricular cerebrospinal 
fluid, it was possible to close the operative incision in the usual manner with 
2 drains of rubber tissue inserted subdurally. Duration, 50 minutes. 

Post-operative Notes. — Uneventful operative recovery in that the incision 
healed per primam and the general condition of the patient so improved that 



OCCURRING AT THE TIME OF BIRTH 731 

he could be discharged from the hospital upon the eighth day post-operative ; 
at that time the headaches had ceased, his mental condition had cleared, 
and the "choked disks" of 5 diopters had lessened to a condition of papill- 
edema of only 1 diopter of swelling ; the vision of the right eye had definitely 
improved and he was able to stagger unsupported for a distance of 7 or 8 
steps, The operative area bulged slightly beyond the flush of the surround- 
ing scalp and pulsated normally. 

Last Report — December 6, 1919 (5 months after operation). — Letter 
from district nurse states that, ' ' marked improvement continued during the 
first three months after the operation, but he is at a stand-still for the last 
six weeks ; the operative incision bulges tensely ; no complaints, however. ' ' 

Remarks. — In spite of the history that this boy was perfectly well at 
the time of the cranial injury nine months ago, it is very difficult to conceive 
that the intracranial pressure had not been increased for a longer period 
than nine months on account of the marked pressure atrophy of the bones 
of the vault so that they were only of the thickness of paper, together with 
the advanced degree of secondary optic atrophy. The history, however, 
is negative before the cranial injury — no headaches, no dizzy spells nor 
attacks of vomiting and until the accident occurred, he had been considered 
an unusually healthy boy. Although the cranial injury may have been the 
primary cause of the increased intracranial pressure and the possible tumor 
formation, yet it is more probable that the condition itself would have 
developed irrespective of the cranial injury, and that the cranial injury was 
merely an incident in the clinical history of this patient or, at most, it had 
precipitated the acute ventricular blockage and the more rapid progress of 
the growth of the tumor. It must be remembered, however, that the path- 
ology in this patient may not be that of a tumor formation, but that the 
ventricular dilatation is the result of adhesions occurring in the subtentorial 
fossa following the organization of a subtentorial hemorrhage which had 
occurred there at the time of the cranial injury and that the signs of right 
cerebellar disease were due to trauma at the time of the cranial injury of 
the right half of the cerebellum ; the absence of these latter signs, however, 
is significant until the patient had entirely recovered from the effects of 
the cranial injury for a period of one month following it. 

The more advanced stage of the secondary optic atrophy being present 
in the left eye, and especially a greater visual impairment of this eye, may 
have resulted in part from a direct damage to the left occipital lobe lying 
beneath the site of fracture of the left half of the occipital bone ; this is very 
much doubted, however, because there were no signs of visual impairment 
of either eye until 2 months following the cranial injury, and a direct 
trauma to the left occipital lobe would have produced immediately a right 
homonymous hemianopsia — and this was at least not ascertained. 

The positive tuberculin test is significant, especially in the absence of a 
pulmonary focus, or one to be found elsewhere in the body; the increased 
cell count of the cerebrospinal fluid, and especially the presence of lympho- 
cytes, were very suggestive; also the fact that tuberculomata, and particu- 
larly of the base and subtentorial fossa, are the most common forms of intra- 
cranial tumor occurring in children under 12 years of age and particularly 



732 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

cerebellar tumors — these facts would tend to indicate that this tumor — if a 
tumor in reality is present — is one of tuberculous character. There were 
no signs of tuberculous nodules upon, the pia-arachnoid in the sulci and 
about the supracortical vessels as disclosed at operation ; these findings are 
rather common in the presence of tuberculomata at the base. 

Naturally, a longer period of time must elapse following the operation 
before it can be stated with any degree of certainty that this patient has 
been permanently improved. It is most unfortunate, however, that the 
high intracranial pressure could not have been lowered at a much earlier 
date than at least 9 months following its inception — the impairment of 
vision could have been thus prevented and a more hopeful prognosis assured 
— at least temporarily. A further report of this patient will be made later 
in a series of cases of brain tumors. 

Case 195. — Chronic severe brain injury followed by an increasing intra- 
cranial pressure with resulting secondary optic atrophy, left hemiplegia and 
mental impairment. Right subtemporal decompression and exploration dis- 
closing a large subcortical tumor of the right occipital lobe — a tuberculoma. 
Death; post-mortem examination. 

No. 1083.— David. Eight years. White. School. U. S. 

Admitted August 12, 1919 — 15 months after cranial injury. Audubon 
Hospital. Referred by Doctor G. F. Boehme. 

Operation August 20, 1919. Right subtemporal decompression and 
exploration. 

Died August 21, 1919 — 16 hours after operation. 

Family histoid negative j two brothers and one sister younger than the 
patient and all perfectly well ; no miscarriages for mother. 

Personal History. — First child, full term, instrumental delivery (low 
forceps) ; apparently normal after birth and except for the usual diseases of 
childhood, the patient was perfectly well in every way until the cranial 
injury. Fifteen months ago, while playing upon a shed, the patient fell 
headlong to the ground, striking the right side of the back of his head 
against a stone ; immediate loss of consciousness ; no bleeding from nose, 
mouth or ears. Patient was taken home and remained unconscious for 
16 hours and then semiconscious during the following week ; gradually recov- 
ered so that at the end of 6 weeks, patient was considered well enough to 
return to school ; no abnormalities were observed by his teacher or rela- 
tives. Ten months ago (5 months after cranial injury), child began to com- 
plain of severe frontal headache on an average of twice a week and lasting 
for a period of 21 hours. Three months later (7 months ago), severe vomit- 
ing spells occurred following the beginning of the weekly headaches and with 
no relation to the meals — in fact, the patient refused to eat anything after 
the headaches began. Four months later (3 months a-go), it was noticed 
for the first time that the child was unable to see as well as formerly and 
this visual impairment has rapidly progressed during the past three months, 
during which time it has been noticed that the left arm and left leg had 
become definitely weaker than the right arm and right leg and that the left 
side of the face exhibits the cortical type of left facial paralysis (the left 
forehead muscles not being involved). Patient has not been able to walk 



OCCURRING AT THE TIME OF BIRTH 



733 



alone during the past 6 weeks and he always falls toward the left when not 
supported. Mentality has become very much dulled while the headaches 
have become continuous. No convulsive seizures at any time. 

Examination upon admission (15 months after cranial injury and 10 
months after the first complaints). — Temperature, 98.6° ; pulse, 84; respira- 
tion, 26. Well-developed and nourished. Rather drowsy and not interested 
in his surrounding's. Head rather large and rachitic in type ; veins of the 
scalp enlarged and numerous; venules of upper eyelids dilated. Definite 
left hemiplegia but not complete ; unable to walk alone and he drags the left 
leg; unable to hold objects in his left hand. No sensory impairment elicited 
and no astereognosis ascertained. Left facial paralysis of the cortical type. 
No nystagmus or ocular paralyses elicited. No impairment of speech. No 
intention tremor of either 
hand. Hearing negative ; 
otoscopic examination nega- 
tive. Vision markedly im- 
paired in that he cannot dis- 
tinguish objects with either 
eye — only the difference be- 
tween light and darkness (no 
hemianopsia could therefore 
be ascertained at this late 
stage) . Pupils equal, slightly 
enlarged, but react to light 
normally. Reflexes : patel- 
lar very much exaggerated, 
left more than right; no 
ankle clonus but left Babin- 
ski well defined and only a 
suggestive right Babinski at 
times; abdominal reflexes — 
left absent, right depressed; 
deep reflexes of left arm in- 
creased. Fundi — retinal veins dilated, tortuous and buried in edematous 
tissue in places ; bilateral ' ' choked disks ' ' of 6 diopters with beginning con- 
nective tissue formation so that a whitish appearance is presented. Lumbar 
puncture — clear cerebrospinal fluid under high pressure (40 mm.) ; Wasser- 
mann test negative and the cell count was* 14 cells per c.mm. and all were 
lymphocytes. X-ray (Doctor A. J. Quimby) — "there are indentures in the 
inner plate of the skull, corresponding to cerebral convolutions and indi- 
cating an increased intracranial pressure; the sella turcica is above normal 
in size" (Fig. 218). Tuberculin skin test negative. 

Treatment. — The high intracranial pressure sufficient to produce a 
bilateral choking of the disks with a resulting secondary optic atrophy 
should have been lowered months ago, whether a definite diagnosis of the 
intracranial lesion could have been made or not — the therapeutic indication 
is the same and that is to lower the increased intracranial pressure and 
therefore prevent the visual impairment at least and then later, it may be 




Fig. 218. — Convolutional markings of pressure atrophy 
of the inner table of the vault due to a prolonged increase of the 
intracranial pressure in a patient developing a large tubercu- 
loma of the right occipital lobe following an injury of the over- 
lying vault of the skull. 



734 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 



possible to locate and to diagnose the intracranial lesion itself and if possible 
it can then be removed—and the patient be not blind. The left hemiplegia 
in the absence of the definite signs of subtentorial and cerebellar disease 
indicated a lesion, and most probably a large tumor, of the right cerebral 
hemisphere and therefore a right subtemporal decompression and explora- 
tion was advised. 

Operation (15 months after cranial injury). — Right subtemporal de- 
compression and exploration : usual vertical incision, bone removed, and no 
complications ; the thickness of the bone was not more than that of a sheet of 
paper and due to prolonged pressure atrophy. Dura pale, non-vascular and 
under high tension; in the hope that the ventricles might be dilated and 
therefore the cerebral tension lowered by means of a ventricular puncture, 

so that little or no damage 
would occur to the underly- 
ing cortex upon enlarging 
the dural opening, a small 
dural incision was made and 
a ventricle puncture needle 
inserted to a depth of 3 cm., 
when a small amount of clear 
cerebrospinal fluid escaped 
and then ceased; another 
puncture about one inch 
posteriorly also permitted a 
small amount of clear cere- 
brospinal fluid to escape 
under tension, but the right 
lateral ventricle could not be 
considered as being dilated. 
It was therefore obligatory 
to enlarge the dural opening 
without first having been 
able to lower markedly the 
high intracranial pressure 
and it was feared that the underlying cerebral cortex of the temporal 
lobe would be damaged. Upon enlarging widely the dural opening, 
a small amount of clear cerebrospinal fluid escaped and the underlying 
cerebral cortex tended to protrude through the dural opening. Using the 
blunt ventricular puncture needle to explore the right cerebral hemisphere, 
a tumor mass, the size of an orange, was located subcortically in the right 
occipital lobe and near the base ; as there were small whitish nodules scattered 
about the supracortical vessels in the sulci in the pia-arachnoid, the condition 
was considered as being one of tuberculous character and the tumor most 
probably a large tuberculoma, so that no attempt was made to remove it for 
fear of precipitating an acute tuberculous meningitis. The presence of the 
tumor in this location explained the collapse of the right ventricle and the 
large size of the tumor produced the high intracranial pressure even in 
the absence of ventricular blockage. Usual closure with 2 drains of rubber 




Fig. 219. — Extreme intracranial pressure in a patient 
having a large tuberculoma of the right occipital lobe and caus- 
ing a marked protrusion of the right decompression area and 
the subsequent death of the patient. 



OCCURRING AT THE TIME OF BIRTH 



735 



tissue inserted ; it was necessary, in order to obtain an accurate closure of 
the temporal muscle and fascia, to sacrifice a small portion of the right tem- 
poral lobe which had been herniated through the decompression opening by 
the high cerebral tension and this was accomplished with no complications- 
Duration, one hour. 

Post-operative Notes. — A very acute cerebral edema occurred as a result 
of the operative trauma; the decompression area bulged tensely and the 
child did not regain complete consciousness (Fig. 219). Within eight hours, 
the temperature ascended to 106.4°, the pulse- and respiration-rates to 148 
and 38, respectively, and the child died 16 hours after the operation. 

Post-mortem Examination. — No fracture of the skull ascertained. Cere- 
bral pressure had been so high that the right temporo-sphenoidal lobe was 
herniated into the decompression opening. No gross hemorrhage. Tumor 
mass, the size of an orange, in the right occipital lobe — 2 cm. beneath the 
cortex and not attached 
to the base of the skull 
(Fig. 220). Throughout 
the pia-arachnoid were 
numerous tuberculous no- 
dules. Right ventricle 
compressed and almost 
obliterated by the tumor 
mass; no blockage of the 
third ventricle. Patho- 
logical report of tumor 
(Doctor Jeffries) — "a 
tuberculoma. ' ' 

Remarks. — The opera- 
tive findings of a large 
subcortical tumor of the 
right occipital lobe, to- 
gether with the whitish 

nodules in the pia-arachnoid about the supracortical vessels in the sulci and 
in the presence of an increased cell count of the cerebrospinal fluid and 
especially of lymphocytes, pointed to this tumor as being a tuberculoma — 
in spite of the negative tuberculin skin test, a negative test being possibly 
more common in this type of tuberculosis than in any other form ; this 
opinion was confirmed by the report of the pathologist. 

If this patient could have been examined earlier before such a marked 
degree of secondary optic atrophy had occurred, it is very probable that a left 
homonymous hemianopsia could have been demonstrated due to an impair- 
ment of the visual cells and their tracts in the right occipital lobe ; it would 
have been then a comparatively simple matter to locate the intracranial 
lesion, although, as has been stated repeatedly in this book, it is not o\' so 
much importance to the patient to locate accurately the lesion as it is to offset 
its pressure effects — spare the vision, lessen the mental impairment and 
then if the lesion is a removable one surgically, to do so after a decompression 
has first been performed, so that the increased intracranial pressure has been 




Fig. 220. — A tuberculoma of the right occipital lobe of the size 
of a small orange — 2 l /i inches in diameter. A secondary optic atro- 
phy of advanced degree prevented the presence of an earlier left 
homonymous hemianopsia from being ascertained. 



736 DIAGNOSIS AND TREATMENT OF BRAIN INJURIES 

sufficiently lowered to permit a safe removal of the lesion with as little 
damage as possible to the surrounding 1 cerebral tissues. 

It is rare for an increased intracranial pressure to reach such a height 
as to produce ' ' choked disks " of 5 diopters plus and, if prolonged, its result- 
ing secondary optic atrophy, unless the ventricles are blocked and thus 
producing an internal hydrocephalus or unless the tumor is a very large 
supratentorial one ; naturally, the blockage* of the ventricles may be due to 
a small tumor situated in the posterior basal areas and subtentorially, and 
also very frequently due to a meningeal exudate and resulting adhesions; 
it is rare for an external hydrocephalus due to blockage of the stomata of 
exit of the cerebrospinal fluid into the supracortical veins and sinuses to 
produce a sufficiently high intracranial pressure as to cause the condition 
of double "choked disks" and the resulting secondary optic atrophy. 



These case-histories have been reported in detail in the hope that they 
will be of assistance in the . diagnosis and treatment of similar conditions 
occurring in new-born babies, in children and in adults; the appropriate 
treatment — whether the expectant palliative or the operative — instituted 
at the time of the acute condition and not delayed in its chronic form until 
years later, in the hope that the patient will "outgrow" it. An attempt 
has been made to recognize the common mistakes in the diagnosis by routine 
post-mortem examinations cor the benefit of future patients and thus avoid 
the burying of our mistakes with the patient. 



INDEX 



Abscess of brain following cranial injury, 611 
Age, influence of, in brain injuries, 146, 150 
Adults, brain injuries in, acute, 4 

chronic, 7 
Alcohol, in cases of brain injury, 457 

a factor in increasing mortality, 354 
Alcoholism, chronic, treatment of, in brain injury, 311 

complicating cerebral concussion, 152 

influence of, in brain injuries, 37, 39, 40, 277 
Anesthesia, local, for operation in fractures of vault, 182 
Aphasia, motor, following cranial injury, 286, 567, 586 
Apoplexy, cranial, decompression operation for, 113 
Asepsis in brain injuries, 79 

Babies, brain injuries in, 9 

Babinski reflex, 38 

Bilateral decompression operation in brain injuries, 244 

Binet mental tests in spastic paralysis, 653 

Bleeding from ear following fracture of skull, 186 

Blood in cerebrospinal fluid after fracture of skull, 190 

Blood-pressure in acute brain injuries, 30 

Bone wax, 95 

Brain, concussion of, 47, 48 

abscess; decompression plus drainage in, 120 
plus exploration in, 116 
ophthalmoscopic findings in, 57 
injuries, acute, complicated by other conditions, 381 
brain tumor, 395 
cerebrospinal lues, 397, 399 
delirium tremens, 382, 396 
mental derangements, 391 
" contre-coup " type, 34 
fracture of skull, 157 
in adults, 4 
in children, 538 

Case 000. Brain injury, acute; extensive fracture of vault; signs 
of increased intracranial pressure eighteen hours later; operation ; 
recovery, 539 
expectant palliative treatment of, 539 

mild increase of intracranial pressure; repeated lumbar punctures and 
drainage; excellent recovery, 559 
Case 144. Brain injury, acute severe, with subdural hemorrhage 
and mild increase of intracranial pressure; several Jackson inn 
convulsive seizures; repeated lumbar puncture and drainage; 
recovery, 559; remarks, 561 
Case 145. Brain injury, acute severe; no fracture of skull nor 
increase of intracranial pressure: localised Jacksonian con- 
vulsions eight hours after injury: no operation: repeated 
lumbar punctures and drainage: recovery, 562; remarks. 564 
Case l.'iG. Brain injury, acute severe, with subdural hemorrhage 
and mild increase of intracranial pressure: motor aphasia: 
repealed lumbar punctures and drainage; recovery, 565- re- 
marks, 566 
Case l'/7. Brain injury, acute severe; extensive linear fractures 
o) vault; mild increase of intracranial pressure: no operation; 
repeated lumbar punctures and drainage; recovery, 567 
marks, 569 

47 m 



73 8 INDEX 

Brain injuries, acute, in children ; mild increase of intracranial pressure ; repeated lum- 
bar punctures and drainage; excellent recovery. 

Case 1J/8. Brain injury, acute severe; extensive comminuted 
linear fracture of vault and base of skull; mild increase of 
intracranial pressure; no operation ; repeated lumbar punctures 
and drainage; recovery, 569 ; remarks, 572. 
of varying degree; no increase of intracranial pressure; no operation; 
excellent recovery, 542 

Case 135. Cranial injury, acute, with cerebral concussion and 
mild shock; no increase of intracranial pressure; expectant 
palliative treatment; recovery, 542; remarks, 543 

Case 136. Cranial injury, acute, icith cerebral concussion, severe 
shock and fracture of vault; no increase of intracranial pres- 
sure; no operation; recovery, 543; remarks, 545 

Case 137. Cranial injury, acute; possible depressed fracture of 
vault; exploratory hwision — no depression; recovery, 545; re- 
marks, 546 

Case 138. Cranial injury, acute, simulating depressed fracture of 
vault; exploratory incision of the scalp; no depression ascer- 
tained; recovery, 546; remarks, 548 

Case 139. Fractures, linear, of both tables of vault underlying 
extensive hematoma of scalp; no increase of intracranial pres- 
sure; no operation except drainage of hematoma; recovery, 548; 
remarks, 550 

Case 140. Brain injury, acute mild; extensive linear fracture of 
vault; no increase of intracranial pressure; no operation; re- 
covery, 551; remarks, 551 

Case HI. Brain injury, acute; fracture of vault with small sub- 
dural hemorrhage; mild increase of intracranial pressure; no 
operation ; recovery, 552; remarks, 553 

Case 1J/.2. Cranial injury, acute severe, with fracture of base of 
skull; no increase of intracranial pressure; no operation; re- 
covery , 554; remarks, 556 

Case Uf3. Brain injury, acute severe; multiple compound linear 
fractures of vault; streptococcic infection of cranial wound and 
symptoms of meningeal irritation ; no operation; anti-strepto- 
coccilc serum treatment; recovery, 557; remarks, 558 
with depressed fracture of vault; removal of depressed bone; excellent 
recovery, 573 

Case 149. Fracture of vault, acute depressed ; extensive linear 
fracture ; no increase of intracranial pressure; removal of de- 
pressed bone; recovery, 573; remarks, 574 

Case 150. Brain injury, acute severe; extensive fractures of vault 
and depressed fracture of right parietal bone; no intracranial 
lesion nor increased pressure; operation; recovery, 575; re- 
marks, 577 

Case 151. Brain injury, acute severe; depressed fracture of skull 
and marked increase of intracranial pressure; laceration of 
right frontal lobe; subtemporal decompression ; removal of de- 
pressed area of bone; recovery, 577; remarks, 579 
with increased intracranial pressure; subtemporal decompression and 
drainage; excellent recovery, 580 

Case 152. Brain injury, acute severe; fracture of base of skull 
and high intracranial pressure due to cerebral edema; right 
subtemporal decompression and drainage; recovery, 580; re- 
marks, 581 

Case 153. Brain injury, acute severe; fracture of base of skull 
and high intracranial pressure; right subtemporal decompres- 
sion and drainage; recovery, 582; remarks, 583 

Case 154. Brain injury, acute severe; linear and depressed frac- 
tures of left temporo-parietal area tvith high intracranial pres- 
sure; motor aphasia and right facial toeakness ; left subtemporal 
decompression and drainage; recovery, 584; remarks, 586 



INDEX 739 

Brain injuries, acute, in children, with increased intracranial pressure; subtemporal de- 
compression and drainage; excellent recovery. 
Case 155. Brain injury, acute severe; increasing intracranial 
pressure due to supracortical hemorrhage; Jacksomwn con- 
vulsive seizures; left subtemporal decompression ami drmnage; 
recovery, 587 ; remarks, 589 
Case 156. Brain injury, acute severe; increasing mtracranial 
pressure due to subdural hemorrhage and cerebral edema; 
aphasia and left facial paralysis; right subtemporal decom- 
pression and drainage; recovery, 589; remarks, 591 
Case 151. Brain injury, acute severe; subdural hemorrhage, cere- 
bral edema and paraplegia; marked increase of intracranial 
pressure; right subtemporal decompression and drainage; re- 
covery, 592 ; remarks, 594 
Case 158. Brain injury, acute severe; fracture of vault and base 
of skull; supracortical hemorrhage and increased intracranial 
pressure; left hemiplegia and Jacksonian convulsive seizures; 
right subtemporal decompression and drainage; recovery, 594; 
remarks, 597 
Case 159. Brain injury, acute severe; fracture of vault and sub- 
dural hemorrhage; increasing intracranial pressure; left sub- 
temporal decompression and drainage; recovery, 598; remarks, 
600 
Case 160. Brain injury, acute severe; fracture of vault and extra- 
dural hemorrhage; increased intracranial pressure; left sub- 
temporal exploration and ligation of middle meningeal artery ; 
recovery, 601 ; remarks, 603 
Case 161. Brain injury, acute severe ; high intracranial pressure 
due to supracortical hemorrhage; loithout fracture; bilateral 
decompression and drainage; recovery, 603; remarks, 605 
in newborn babies, 523 

Case 131. Fracture, recent depressed, of left parietal area of vault of 
skull in newborn child; localizing symptoms and signs; removal of 
depressed area; recovery, 525; remarks, 527 
Case 132. Brain injury, acute severe, in newborn bahy ; supracortical 
hemorrhage and) convulsive tioitohings ; increased intracranial pres- 
sure; left subtemporal decompression and drainage; recovery. 527 ; 
remarks, 530 
Case 133. Brain injury, acute severe, in newborn bahy associated with 
cortical, supracortical and subtentorial hemorrhages and with high 
intracranial pressure; bilateral decompression and drainage: 
autopsy, 531; remark, 533 
Case 134- Brain injury, acute severe, in newborn baby ; increased 
intracranial pressure due to suhdural, supracortical and subten- 
torial hemorrhages and cerebral edema. Bilateral decompression and 
drainage; autopsy, 534; remarks, 537 
laceration of pyramidal tract fibres, 34 
signs of, 16 

general, 25 (see also page 749) 
blood-pressure, 30 
impaired sensation, 34 
pulse, 28 
respiration, 29 
shock, 25 
temperature, 28 
unconsciousness, 35 
local, 17 

bleeding, 19 
contusions, 17 
depression of vault. 19 
ecchymosis, 19 

escape of cerebrospinal fluid, 19 
symptoms of, 1(> 
headache. 10 
nausea and vomiting, 16 



740 INDEX 

Brain injuries, acute, treatment, 22 

venesection in, 32 
acute and chronic, in newborn babies and children, 521 

general considerations, 521 
acute severe, in children, with varying degrees of intracranial lesions; death; 
autopsy, 606 

Case 162. Brain injury, acute severe ; no fracture of skull, intracranial 
hemorrhage or increased intracranial pressure ; severe initial shock; no 
operation; autopsy, 606; remarks, 607 

Case 163. Brain injury, recent severe; supracortical hemorrhage and 
definite localizing signs; no cranial operation; autopsy; sarcomatosis, 
608; remarks, 609 

Case 164- Cranial injury, acute severe; compound linear fracture of right 
vault ; definite weakness of left side of body and increased intracranial 
pressure; local operation; brain abscess and meningitis; autopsy, 610; 
remarks, 611 

Case 165. Brain injury, acute severe; compound depressed fracture of 
vault and penetration of underlying dura; removal of depressed frag- 
ments of bone; purulent meningitis; post-mortem examination, 612; 
remarks, 613 

Case 166. Brain injury, acute severe; compound depressed fracture of 
vault; removal of depressed fragment of bone; cerebral hernia and 
fungus cerebri; left subtemporal decompression and repair of hernial 
protrusion; meningitis; death, 613; remarks, 615 

Case 167. Brain injury, acute severe; fractures of vault and of base and 
extreme cerebral edema; no intracranial hemorrhage; high intracranial 
pressure producing early medullary compression and edema; no opera- 
tion; autopsy, 616; remarks, 618 

Case 168. Cranial injury, acute; fracture of ethmoid and frontal bones, 
ivithout evidence of severe intracranial lesion; no operation ; meningitis ; 
autopsy, 619; remarks, 621 

Case 169. Brain injury, acute severe; linear fracture of vault; tear of 
right middle meningeal artery with sloiv formation of huge extradural 
hemorrhage ; no operation; autopsy, 622; remarks, 624 

Case 170. Brain injury, acute severe; fractures of vault and base and sub- 
dural hemorrhage ; mild increase of intracranial pressure; no operation ; 
purulent meningitis; autopsy, 625; remarks, 627 

Case 171. Brain injury, acute severe; fracture of vault and base; subdural 
hemorrhage ; increasing intracranial pressure; right subtemporal de- 
compression and drainage; acute purulent meningitis; autopsy, 628; 
remarks, 630 

Case 172. Brain injury, acute severe; linear fracture of vault and in- 
creased intracranial pressure; purulent meningitis from infected hema- 
toma; subtemporal decompression and drainage; autopsy, 631; re- 
marks, 633 

Case 173. Brain injury, acute severe; multiple fractures of vault and 
base; extradural and subdural hemorrhages and cerebral edema; high 
intracranial pressure causing medullary compression and edema; right 
subtemporal decompression and drainage; infection; autopsy, 634; re- 
marks, 636 

Case 17 lj. Brain injury, acute severe; compound fracture of vault and 
base and large subdural hemorrahge ; extreme intracranial pressure with 
medullary compression and medullary edema; bilateral decompression 
and drainage; autopsy, G37 ; remarks, 639 

Case 175. Brain injury, acute severe; fractures of vault and base and with 
subdural, cortical and subtentorial hemorrhages; high intracranial pres- 
sure and medullary edema; bilateral decompression and drainage; 
autopsy, 640; remarks, 642 

with and without fracture of skull, complicated by brain tumor, 385 
Case 88. Brain injury, acute severe; increased intracranial pres- 
sure; operative fracture of base of skull; bilateral decom- 
pression and drainage; autopsy; mid-brain sarcoma, 385; re- 
marks, 387 



INDEX 741 

Brain injuries, acute, severe, with and without fracture of skull, complicated by brain 
tumor. 
Case 89. Brain injury, acute severe ; increased intracranial pres- 
sure and fracture of base of skull; left subtemporal decom- 
pression and drainage; autopsy; glioma of left temporo- 
sphenoidal lobe, 388; remarks, 390 

by cerebrospinal lues, 300 

Case 92. Brain injury, acute severe; mild 
intracranial pressure; fracture of base 
of skull; no operation ; delirium tremens 
and cerebrospinal lues; luetic treatment ; 
improved, 396; remarks, 397 

Case 93. Brain injury, acute severe; mild 
intracranial pressure ; cerebrospinal lues ; 
no operation; luetic treatment ; im- 
proved, 398 ; remarks, 399 
by delirium tremens, 381 

Case 86. Brain injury, acute severe; mild 
intracranial pressure and fracture of 
base of skull; no operation; delirium 
tremens; autopsy, 382; remarks, 383 

Case 87. Brain injury, acute severe; high 
intracranial pressure; fracture of base 
of skull; no operation ; delirium tremens; 
recovery, 383 ; remarks, 384 
by meningitis; deatli; autopsy, 361 

Case 80. Brain injury, acute severe; sub- 
dural hemorrhage and fracture of skull; 
intracranial pressure not increased ; no 
operation; meningitis; autopsy, 362: re- 
marks, 364 

Case 81. Brain injury, acute severe; high 
intracranial pressure due to subdural 
hemorrhage ; fracture of left vault and 
base; left subtemporal decompression and 
drainage; meningitis; autopsy, 366: re- 
marks, 367 

Case 82. Brain injury, acute severe; high 
intracranial pressure due to subdural 
hemorrhage and cerebral edema: fracture 
of vault ; left subtemporal decompression 
and drainage; meningitis; autopsy, 368; 
remarks, 370 

Case 83. Brain injury, acute severe; high 
intracranial pressure due to subdural 
hemorrhage and cerebral edema: right 
subtemporal decompression and drai)i- 
age; meningitis; left subtemporal de- 
compression; autopsy, 371: remarks. 373 

Case 84. Brain injury, acute severe; intra- 
cranial pressure not increased ; fracture 
of base of skull; meningitis; right sub- 
temporal decompression and drainage: 
post-mortem examination. 374: remarks. 
376 

Case 8.~>. Brain injur}/, acute serere: 
slightly increased intracranial pressure: 
fracture of vault and base or skull; men- 
ingitis; right mastoiditis : mastoidec- 
tomy; brain abscess; left subtemporal 
decompression and drainage; autopsy, 
377 : remarks. 3 SO 
bv mental derangements, 391 



74 2 INDEX 

Brain injuries, acute severe, with and without fracture of skull, complicated by mental 

derangements, 391 
Case 90. Brain injury, acute severe ; high 
intracranial pressure and fracture of 
base of skull; left subtemporal decom- 
pression and, drainage; mental and 
emotional impairment; recovery, 391; 
remarks, 393 
Case 91. Brain injury, acute severe; high 
intracranial pressure and fracture of 
base of skull; right subtemporal decom- 
pression and drainage; mental and emo- 
tional impairment; recovery, 394;: re- 
marks, 395 
with high intracranial pressure due to hemorrhage 
and cerebral edema; subtemporal decompres- 
sion; autopsy, 322 
high mortality in, 322 
Case 69. Brain injury, acute severe, with high 
intracranial pressure and extradural and 
subdural hemorrhage ; right subtemporal de- 
compression and, drainage; autopsy, 323; re- 
marks, 325 
Case 70. Brain injury, acute severe; high intra- 
cranial pressure due to cerebral edema and 
subdural hemorrhage; right subtemporal de- 
compression and drainage; autopsy, 326; re- 
marks, 327 
Case 71. Brain injury, acute severe; subdural 
hemorrhage; marked degree of shock and 
medullary edema; right subtemporal decom- 
pression and drainage; autopsy, 329; re- 
marks, 331 
Case 72. Brain injury, acute severe; high intra- 
cranial pressure due to subdural hemorrhage 
and cerebral edema; left subtemporal decom- 
pression and drainage; autopsy, 334: re- 
marks, 336 
Case 73. Brain injury, acute severe; high intra- 
cranial pressure due to extradural, subdural 
and cortical hemorrhages ; left subtemporal 
decompression and drainage; autopsy; 337; 
remarks, 339 
Case 74. Brain injury, acute severe; high intra- 
cranial pressure due to subdural hemorrhage 
and cerebral edema; left subtemporal decom- 
pression and drainage; autopsy, 341 ; re- 
marks, 342 
Case 75. Brain injury, acute severe; high intra- 
cranial pressure due to subdural hemorrhage 
and cerebral edema ; right subtemporal decom- 
pression and drainage; autopsy, 344: re- 
mark s, 346 
Case 76. Brain injury, acute severe; fracture of 
base of skull and extreme intracranial pres- 
sure; extradural, subdural and intracerebral 
hemorrhages and cortical lacerations ; medul- 
lary compression and incipient medullary 
edema; left subtemporal decompression and 
drainage; medullary edema; autopsy, 348; 
remarks, 351 
Case 77. Brain injury, acute severe ; high intra- 
cranial pressure due to subdural hemorrhage 
and cerebral edema; bilateral decompression 
ana drainage; medullary edema; autopsy, 
352; remarks, 354 



INDEX 743 

Brain injuries, acute severe, with and without fracture of skull, with high intracranial 

pressure due to hemorrhage and cerebral edema, etc. 
Case 78. Brain injury, acute severe; high intra- 
cranial pressure due to subdural hemorrhage 
and cerebral edema; bilateral decompression 
and drainage; medullary edema; autopsy, 
355; remarks, 357 
Case 79. Brain injury, acute severe; perforating 
bullet injury of entire brain; high intra- 
cranial pressure due to subdural, intracerebral 
and ventricular hemorrhage ; bilateral decom- 
pression and drainage; autopsy, 358; re- 
marks, 360 
with extreme intracranial pressure precipitating an acute medullary 
edema; no operation; autopsy, 304 
Case 62. Brain injury, acute severe, with fracture; high intra- 
cranial pressure due to large intracranial hemorrhage, precipi- 
tating medullary edema; no operation; autopsy, 305; remarks, 
306 
Case 63. Brain injury, acute severe; fracture; high intracranial 
pressure due to subdural hemorrhage and cerebral edema; no 
operation; medullary edema; autopsy, 308; remarks, 309 
Case 64- Brain^ injury, acute severe, with high intracranial pres- 
sure due to subdural hemorrhage and cerebral edema; fracture; 
no operation; medullary edema; autopsy, 310; remarks, 311 
Case 65. Brain injury, acute severe, with high intracranial pres- 
sure due to cerebral edema; no operation; medullary edema; 
autopsy, 314; remarks, 315 
Case 66. Brain injury, acute severe, with high intracranial pres- 
sure due to fracture; cerebral edema; no operation; medullary 
edema; autopsy, 316; remarks, 317 
Case 67. Brain injury, acute severe, 'without -fracture; high intra- 
cranial pressure due to large hemorrhage ; no operation ; medul- 
lary edema; autopsy, 318; remarks, 319 
Case 68. Brain injury, acute severe, loithout fracture; high intra- 
cranial pressure due to cerebral edema alone; no operation; 
medullary edema; autopsy, 320; remarks, 321 
with extreme shock and no increase of intracranial pressure: no 
operation; death; autopsy, 296 
Case 58. Brain injury, acute severe, with fracture; severe shook j 
no increase of intracranial pressure; no operation; autopsy. 
297; remarks, 298 
Case 59. Brain injury, acute severe; fracture; severe shock ; no 
increase of intracranial pressure; no operation; autopsy, 299: 
remarks, 300 
Case 60. Brain injury, acute severe; without fracture; severe 
shock; no increase of intracranial pressure ; operation : autopsy, 
302 ; remarks, 302 
Case 61. Brain injury, acute severe, ivithout f radii re: sliock : )io 
increase of intracranial pressure; no operation: autopsy, 303: 
remarks, 304 
with high intracranial pressure due to cerebral edema alone and 
requiring subtemporal decompression and drainage, 273 
Case 51. Brain injury, acute severe; signs of high intracranial 
pressure due to cerebral edema; left subtemporal decom- 
pression and drainage; excellent recovery, 274: remarks. 276 
Case 52. Brain injury, acute severe; high intracranial pressure 
due to cerebral edema; right subtemporal decompression a nil 
drainage; excellent recovery, 277: remarks, 280 
Case 53. Brain injury, acute severe; Jiigh intracranial pressure 
due to cerebral edema; right subtemporal decompression and 
drainage; excellent recovery, 280: remarks. 282 
Case 5'/. Brain injury, acute severe: high intracranial pressure 
due to cerebral edema; left subtemporal decompression and 
drainage; excellent' recovery, 284; remarks, 286 



744 INDEX 

Brain injuries, acute severe, with high intracranial pressure due to cerebral edema 
alone and requiring subtemporal decompression and drainage. 
Case 55. Brain injury, acute severe; high intracranial pressure 
due to cerebral edema; left subtemporal decompression and 
drainage; excellent recovery, 287; remarks, 288 
Case 56. Brain injury, acute severe; high intracranial pressure 
due to cerebral edema; right temporal decompression and drain- 
age; recovery, 289; remarks, 291 
Case 57. Brain injury, acute severe; extreme intracranial pres- 
sure due to high and increasing cerebral edema; bilateral 
decompression and drainage; excellent recovery, 292; re- 
marks, 295 
with high intracranial pressure due to hemorrhage and cerebral edema ; 
subtemporal decompression operation, 243 
Case 42. Brain injury, recent severe; high intracranial pressure 
and subdural hemorrhage; left subtemporal decompression and 
drainage, 245; remarks, 246 
Case Jf3. Brain injury, acute severe, without fracture ; high intra- 
cranial pressure; subdural and subarachnoid hemorrlwge ; left 
subtemporal decompression and drainage, 247 ; remarks, 250 
Case 44- Brain injury, acute severe; high intracranial pressure; 
subdural and cortical hemorrhage ; left subtemporal decom- 
pression and drainage, 250; remarks, 252 
Case Jf5. Brain injury, acute severe; high intracranial pressure; 
subdural and subarachnoid hemorrhage ; repeated lumbar punc- 
tures; left subtemporal decompression and drainage, 253; re- 
marks, 255 
Case J/6. Brain injury, acute severe; increasingly high intra- 
cranial pressure; subdural and cortical hemorrhage ; right sub- 
temporal decompression and drainage, 256; remarks. 258 
Case 1ft. Brain injury, acute severe ; high intracranial pressure; 
extradural and subdural hemorrhage with brain laceration ; sub- 
temporal decompression and drainage, 260; remarks, 261 
Case Jj8. Brain injury, acute severe; extreme intracranial pres- 
sure; subdural and intracerebral hemorrhages ; bilateral decom- 
pression and drainage, 262; remarks, 265 
Case Jf9. Brain injury, acute severe ; extreme intracranial pres- 
sure; subdural and intracerebral hemorrhage ; bilateral decom- 
pression and drainage, 266; remarks, 269 
Case 50. Brain injury, acute severe; extreme intracranial pres- 
sure; extradural, subdural, cortical and intracranial hemor- 
rhage; bilateral decompression and drainage, 270; remarks, 272 
affecting pituitary body, 40 
age, influence of, in, 146, 150 
alcoholism, influence of, in, 37, 39, 40 
aphasia, pure motor, following, 286 
bilateral spasticity following, 537 
cerebral edema following, 393, 395 
choked disks after, 288 
chronic, 415 

complicated by other conditions, 495 
nephritis, 495 

Case 126(a). Brain injury, chronic severe, icith linear frac- 
ture of vault, high intracranial pressure and nephritis; 
right subtemporal decompression ; improvement ; spontane- 
ous hemorrhage 1 into left ventricle; autopsy, 495; re- 
marks, 498 
tumor of brain, 499 

Case 126 ( b ) . Cranial injury, old, icith increased intracranial 
pressure; osteosarcoma of left squamous bone; subcortical 
cerebral sarcoma; operation ; improved, 499 ; remarks, 504 
Case 127. Brain injury, old severe, with increased intracranial 
pressure and later convulsions; right subtemporal decom- 
pression; improvement ; emotional changes later icith in- 
creasing intracranial pressure; left subtemporal decompres- 
sion and exploration; supracortical angiomatous tumor 
mass; improvement, 504; remarks, 508 



INDEX 745 

Brain injuries, chronic, complicated by other conditions, mental derangement, 509 

Case 128. Brain injury, old severe, ivith depressed fracture 
of vault, increased intracranial pressure and melancholy ; 
institutional care; partial craniectomy ; drainage of supra- 
cortical hemorrhagic cyst; recovery, 509; remarks, 511 
Case 129. Brain injury, old severe, with gunshot fracture of 
vault, increased intracranial pressure and symptoms of 
dementia prwcooc ; right subtemporal decompression and, 
removal of depressed area of vault ; supracortical angioma; 
temporary improvement, 512; remarks, 514 
Case 130. Brain injury, old severe; depressed fracture of 
vault; increased intracranial pressure; emotional and 
mental impairment of traumatic dementia type; left sub- 
temporal decompression; improvement, 515; remarks, 517 
epilepsy, traumatic, 417 
fractures of little importance in, 415 
frequency of, 415 
in children, 713 

chronic cerebral edema, 714 
depressed fractures of vault, 713 

Case 189. Brain injury, old severe, with fracture of base of skull 
and convulsive seizures ; mental and emotional impairment, mild 
secondary optic atrophy and increased intracranial pressure; 
operation refused; no improvement, 714; remarks, 715 
Case 190. Brain injury, chronic severe, in child one month old. 
with linear fracture of right vault and spastic hemiplegia, mild 
mental retardation and occasional convulsive seizures ; increased 
intracranial pressure; right subtemporal decompression ; ex- 
ploratory incision; marked improvement, 716; remarks, 718 
Case 191. Brain injury, old severe, loith depressed fracture of left 
parietal vault and signs of increased intracranial pressure; 
right hemiplegia and attacks of petit mat ; left subtemporal de- 
compression; improvement, 719; remarks, 723 
Case 192. Brain injury, chronic severe, with depressed fracture of 
vault and resulting hemiplegia and mental retardation; in- 
creased intracranial pressure; left subtemporal decompression 
and removal of depressed area of bone; marked improvement, 
723; remarks, 726 
Case 19-k- Brain injury, chronic severe, with fracture of vault ; 
later development of internal hydrocephalus and signs of a 
probable tuberculoma of right half of cerebellum; right sub- 
temporal decompression and permanent ventricular drainage: 
marked improvement, 728; remarks, 731 
Case 195. Brain injury, chronic severe, with increasing intra- 
cranial pressure, secondary optic atrophy, left hemiplegia and 
mental impairment; right subtemporal decompression and ex- 
ploration disclosing a tuberculoma; post-mortem examination. 
732; remarks, 735 
occurring at birth, 644 

Case 188. Brain injury at birth, chronic severe, with supracortical 
hemorrhage and marked mental retardation; high intracranial 
pressure; right and left subtemporal decompression and drain- 
age; autopsy; thrombosis of single lateral sinus. 707: re- 
marks, 712 
no fracture of skull; symptoms and signs persisting and due to increased 
intracranial pressure, 487 
Case 123. Brain injury, old severe; no fracture of skull but increased 
intracranial pressure; severe headaches and emotional disturbances; 
right subtemporal decompression ; recovery, 488; remarks. 489 
Case 12j. Brain injury, old severe; no fracture of skull but increased 
intracranial pressure; severe headaches, dizzy spells and emotional 
disturbances; right subtemporal decompression; recovery, 400: re- 
marks. 492 



746 INDEX 

Brain injuries, chronic; no fracture of skull; symptoms and signs persisting and due 
to increased intracranial pressure. 

Case 125. Brain injury, chronic severe; cortical and supracortical 

hemorrhagic cyst formation directly beneath site of bullet-injury of 

vault; no fracture; mental retardation, emotional instability and 

Jacksonian convulsive seizures; no operation; death from opium 

• poisoning ; autopsy, 492; remarks, 494 

operation in, 415 

usual intracranial lesion, producing', 415 
with depressed fracture of vault, 418 

Case 98. Brain injury, old; depressed fracture of left occipital bone; 
right homonymous hemianopsia; symptoms and signs persisting; 
operation advisable but refused, 418; remarks, 420 

Case 99. Brain injury, old severe, with penetrating bullet wound of 
brain and increased intracranial pressure; slight left hemiplegia; 
no operation ; symptoms and signs persisting, 421/ remarks, 423 

Case 100. Brain injury, old severe; depressed fracture of vault and 
increased intracranial pressure; immediate removal of depressed 
area of bone ; symptoms and signs persisting ; operation advisable, 
423; remarks, 425 
with depressed fracture of vault and persisting symptoms and signs; minor 
and major epilepsy; operation, 432 

Case 108. Brain injury, old, with depressed fracture of vault of skull; 
symptoms and signs persisting ; removal of depressed bone; excellent 
recovery, 433; remarks, 434 

Case 104- Brain injury, old; depressed fracture of vault with in- 
creased intracranial pressure; symptoms and signs persisting ; re- 
moval of bony d&pression ; excellent recovery, 434; remarks, 436 

Case 105. Brain injury, old severe; with depressed fracture of skull 
and increased intracranial pressure; convulsive seizures and hemi- 
plegia; right subtemporal decompression; improvement, 437; re- 
marks. 439 

Case 106. Brain injury, old severe; depressed fracture of vault and 
increased intracranial pressure; mild left hemiplegia with later 
convulsive seizures; right subtemporal decompression ; improvement, 
440 ; remarks, 442 

Case 107. Brain injury, old severe; depressed fracture of left parietal 
area of vault and increased intracranial pressure; right hemiplegia 
and petit mal; left subtemporal decompression; improvement, 443; 
remarks, 445 

Case 108. Brain injury, old severe; depressed gunshot fracture of 
vault and increased intracranial pressure; removal of depressed bone 
alone and insertion of silver plate; convulsive seizures; right sub- 
temporal decompression and removal of silver plate; improvement, 
446; remarks, 448 

Case 109. Brain injury, old severe; depressed fracture of vault andl 
increased intracranial pressure; convulsive seizures. Tico operations : 
left subtemporal decompression and removal of depressed area of 
bone; improvement, 449; remarks, 451 

Case 110. Brain injury, old severe ; depressed fracture of right frontal 
bone and increased intracranial pressure; petit mal and severe head- 
ache. Two operations: right subtemporal decompression and re- 
moval of depressed area of vault; recovery, 452; remarks, 454 

Case 111. Brain injury, old severe ; depressed fracture of left parietal 
area of vault and increased intracranial pressure; paraphasia and 
convulsive seizures. Two operations : left subtemporal decompression 
and removal of silver plate covering bony defect ; excellent recovery, 
454; remarks, 457 

Case 112. Brain injury, old severe; depressed fracture of left frontal 
bone and in<yreased intracranial pressure ; convulsive seizures. Two 
operations : left subtemporal decompression and removal of depressed 
area of bone; improvement, 457; remarks, 461 
with fracture of base of skull, 427 

Case 101. Brain injury, old severe; fracture of base of skull and 
increased intracranial pressure; partial secondary optic atrophy; 
symptoms and signs persisting ; operation advisable, 428; remarks, 
429 



INDEX 747 

Brain injuries, chronic, with fracture of base of skull. 

Case 102. Brain injury, old severe; fracture qf base of skull and in- 
creased intracranial pressure; convulsive seizures: symptoms and, 
signs persisting; operation refused, 430; remarks, 431 

and symptoms and signs persisting; minor and major epi- 
lepsy; subtemporal decompression, 461 
Case 113. Brain injury, old severe; fracture of skull and 
increased intracranial pressure ; convulsive seizures : 
right subtemporal decompression; excellent recovery, 
462; remarks, 463 
Case lllf. Brain injury, old severe; fracture of base of 
skull and increased intracranial pressure; convulsive 
seizures and motor aphasia with mild hemiparesis ; 
left subtemporal decompression ; recovery, 464; re- 
marks, 466 
Case 115. Brain injury, old severe; fracture of base of 
skull and increasing intracranial pressure; convulsive 
seizures; right subtemporal decompression; recovery, 
466; remarks, 468 
Case 116. Brain injury, old severe; fracture of base of 
skull and increased intracranial pressure; convulsive 
seizures; right subtemporal decompression; improve- 
ment, 469; remarks, 471 
Case 111. Brain injury, old severe; fracture of the vault 
and base of skull and increased intracranial pressure ; 
continuous severe headache and spells of petit mal; left 
subtemporal decompression ; recovery, 472 ; remarks, 474 
Case 118. Brain injury, old severe; fracture of base of 
skull and increased intracranial pressure ; convulsive 
seizures ; right temporal decompression ; improvement, 
474; remarks, 477 
Case 119. Brain injury, old severe; fracture of skull and 
increased intracranial pressure; convulsive seizures; 
left subtemporal decompression; improvement, 477: 
remarks, 479 
Case 120. Brain injury, old severe; fracture of occipital 
bone and increased intracranial pressure; convulsive 
seizures; right subtemporal decompression; improve- 
ment, 480; remarks, 481 
Case 121. Brain injury, old severe; fracture of base 
of skull and increased intracranial pressure: severe 
headache and convulsive seizures left subtemporal de- 
compression ; improvement of headache but only tem- 
porary lessening of convulsions, 483; remarks, 485 
Case 122. Brain injury, old severe ; possible fracture of 
base of skull and increased intracranial pressure: 
severe headache and convulsive seizures. .Right sub- 
temporal decompression; improvemtirt temporary. 485 : 
remarks, 487 
clinical syndrome in, importance of, 239 
complicated by other conditions, 495 
mental derangement, 509 
nephritis, 495 
tumor of brain, 499 
" contre-coup " effect of, on brain, 348 
convulsions following, 13 

dangers of insertion of protection plate, 457 
decompression plus drainage, 117 
fracture of skull in relation to, 11 
general considerations, 11 
gun-shot wounds, 8 
hearing, impairment of, following, 280 
in adults, acute, 141 

cerebral concussion, 142 (see Concussion, cerebral) 
acute and chronic, illustrative cases, 139 
chronic, 7 
in babies, acute, 9 



74 8 INDEX 

Brain injuries in children, 9 
chronic. 10 
rapid recovery, 556 
in newborn babies, 9 
in obese persons, 147 
infection, precautions against, 148, 150 
influence of alcoholism in, 277 
lumbar punctures, repeated, in, 165 

therapeutic use of, 47 
mild recent, with fracture of base of skull and increased intracranial pressure; 
no operation, 182 
Case 17. Fracture of base of skull; mild increase of intracranial pressure; 

no operation; repeated lumbar punctures, 184: remarks, 185 
Case 18. Fracture of base of skull; mild increase of intracranial pressures- 
no operation, 187 ; remarks, 188 
Case 19. Fracture of base of skull; mild increase of intracranial pressure; 

no operation, 189 
Case 20. Brain injury, acute severe; increased intracranial pressure; no 

operation, 191; remarks, 193 
Case 21. Fracture of base of skull; increased intracranial pressure; no 
operation; repeated lumbar punctures; doubtful recovery, 194; re- 
marks, 196 
diagnosis and treatment, 3, 4 
recent advances in, 1 
drainage in, 11 
effect of alcohol in, 457 
epilepsy following, 36, 72 
fractures of base, 73 

Case 22. Fracture of base of skull ; increased intracranial pressure; no 
operation; repeated lumbar punctures; doubtful recovery, 196; re* 
marks, 197 
Case 23. Fracture of base of skull; increased intracranial pressure; no 

operation; doubtful recovery, 198; remarks, 199 
Case 2^. Fracture of base of skull; marked increase of intracranial pres- 
sure; no operation; excellent recovery. 200: remarks, 201 
Case 25. Fracture of base of skull; marked increase of intracranial pres- 
sure; no operation, 202: remarks. 203 
Case 26. Fracture of base of skull; marked increase of intracranial pres- 
sure ; no operation, 204; remarks, 205 
Case 27. Fracture of base of skull; marked increase of intracranial pres- 
sure; operation refused; doubtful recovery, 205; remarks, 207 
Case 28. Fracture, acute, of base of skull; marked increase of intracranial 

pressure; operation refused; doubtful recovery, 208; remarks, 209 
Case 29. Fracture of base of skull ; marked increase of intracranial pres- 
sure; no operation; doubtful recovery, 210; remarks. 211 
Case 30. Fracture of base of skull ; markedly increased intracranial pres- 
sure; no operation; doubtful recovery, 212; remarks, 213 
Case 31. Fracture, acute, of base of skull; marked increase of intracranial 

pressure; no operation; doubtful recovery, 214; remarks, 216 
Case 32. Fracture of base of skull, acute ; marked increase of intracranial 
pressure; no operation; repeated lumbar punctures; doubtful recovery, 
217; remarks, 218 
Case 33. Fracture of base of skull, acute; marked increase of intracranial 
pressure; no operation ; repeated lumbar punctures ; doubtful recovery^ 
220; remarks, 221 
Case 34. Fracture of base of skull, acute; marked increase of intracranial 
pressure; no operation; doubtful recovery, 222; remarks, 223 
mild, with depressed fracture of vault ; with or without fracture of base, 224 
Case 35. Fracture of base, acute; depressed fracture of vault of skull; mild 
increase of intracranial pressure; removal of depressed area of bone, 
then a subtemporal decompression, 226; remarks, 227 
Case 36. Same as 35, 228; remarks, 229 
Case 37. Same as 35, 231 : remarks, 232 

Case 38. Fracture of base, acute; depressed fracture of vault; mild in- 
crease of intracranial pressure; subtemporal decompression, then removal 
of depressed area of bone, 233; remarks, 235 



INDEX 749 

Brain injuries, mild, with depressed fracture of vault; with or without fracture of base. 
Case 39. Fracture, recent, of base; compound depressed fracture of vault; 
high intracranial pressure; subtemporal decompression, then removal of 
depressed area of bone, 235; remarks, 237 
Case 40. Same as 38, 237 ; remarks, 239 
Case U> Same as 38, 240; remarks, 242 
mortality from, 3, 4 

operative percentage, 7 
otoscopic examination in, 162, 188 

value of, 145 
facial paralysis following, 191 
of right side, 287 
temporary, 280 
operation for, 4, 11 

contra-indicated, 5 
decompression, 6 

in fracture of skull, 6 
in gun-shot and stab wounds, 8 
following recovery, 8 
repeated, 7 
paralyses following, 13 

recuperative ability of children having, 543 
reflexes after, 203 
roentgenograms in, 283 
Rontgen-rays in, 6, 11, 12 

severe, with increased intracranial pressure and hemorrhage; unilateral or bi- 
lateral decompression operation, 245 
signs., general, 25 

blood-pressure, 30 
cerebral edema, 47 
convulsive seizures, 36 
impaired sensation, 34 
lumbar puncture findings, 44 

free blood in cerebrospinal fluid, 45 
measurement of intracranial pressure, 45 
ophthalmoscopic findings, 41 
choked disk, 41, 52 
paralysis, 32 
pulse, 28 
pupillary changes, 39 

constriction and " pin-point " pupils, 39 
inequality of pupils, 39 
reflexes, 37 

Babinski, 38 
Chaddoek, 37 
Hoffman, 38 
respiration, 29 , 
restlessness, 35 
shock, 25 
temperature, 28 
unconsciousness, 35 
urinary findings, 40 
stab wounds, 8 

stage of medullary collapse, 5 
symptoms following recovery from, 7 
treatment of, 70 

according to ophthalmoscopic findings, 84 

application of heat, 74 

aseptic measures, 79 

catharsis, 77 

cold compresses to head, 7S 

decompression and drainage, 72 

subtemporal, 73 
diet, 78 
drugs, 78 

expectant palliative, 70, 74 
for shock, 74 
general considerations, 70 



750 INDEX 

Brain injuries, treatment of, lowering of intracranial pressure, 70 
lumbar puncture drainage, 80 
morphia, 76 
operative, 82 

choice of operation, 86 
complications following, 110 
indications for and against, 84 
osteoplastic ''flap " operation, 86 
time for, 72 

when contra-indicated, 85 
palliative versus operative, 71 
post-operative, 106 
principles governing, 118 
relief of shock, 71 
rest in hed, quiet and warmth, 77 
subtemporal decompression operation. 86 
technic of, 88 

controlling bleeding, 95 
incising the dura, 99 
insertion of drain, 102 
making incision, 90 
preparation of patient, 88 
suturing and bandaging of wound, 103 
vertical incision, 87 
with extensive hematoma, 79 
" wet " brain following, 36, 40, 48 
with fracture of base of skull, diagnosis, 183 

with high intracranial pressure and subdural hemorrhage,, pupillarv finding's 
in, 246 
due to hemorrhage and cerebral edema, requiring subtemporal 
decompression, 243 
with increased intracranial pressure, prognosis, 244 
tumors, decompression plus exploration in, 116 
ophthalmoscopic findings in, 57 
removal of, 110 

subtemporal decompression operation for, 114 
"wet," 8, 12, 36 
Bullet wound of brain, 423 

Cardio-vascular diseases as possible factors of post-traumatic neurosis, 404 

Catharsis in brain injuries, 77 

Cerebral concussion, 142 (see Concussion, cerebral) 

edema, acute, cranial decompression operation for, 113 
increased intracranial pressure due to, 239 
chronic, with intracranial hemorrhage, 194 
following cranial injury, 393, 395 

with increased intracranial pressure, 244 
the cause of high intracranial pressure, 273 
spastic paralysis in children, 644 

lesions of brain producing, 645 
causal differentiation, 58 

intracranial hemorrhage in, pathology of, 115 
ophthalmoscopic findings in, 58 
subtemporal decompression operation for, 115 
Cerebrospinal fluid, 49 

at lumbar puncture, measurement of, in brain injury, 252 
direction of flow of, 292 
normal pressure of, 65 
Chaddock reflex, 37 
Children, brain injuries in, 9 
acute, 522, 538 
chronic, 713 
occurring at birth, 644 
development of, following- trauma at birth, 521 
Choked disk, 55 

in brain injuries, 41, 52, 288 
in brain tumors, 57 



INDEX 751 

Choked disk in intracranial hemorrhage and cerebral edema, 59 
Clinical syndrome, importance of, in brain injuries, 239 
Compresses, cold, in brain injuries, 78 
Compression, intracranial (see Intracranial compression) 
Concussion, cerebral, 47, 48, 142 1 
case history, 143, 145, 147 
complications of, 147 
alcoholism, 152 
existing mental derangement, 154 

Case 6. Cerebral concussion, severe, alcoholism, 152; remarks, 154 
Case 7. Cerebral concussion, severe, occurring in patient mentally 
deranged; paranoia, 154; remarks, 155 
hematoma, 149 

Case 4- Concussion ; extensive hematoma ; multiple contusions ; dislo- 
cation of both shoulders, 149; remarks, 150 
lacerations of scalp, 147 

Case 3. Cerebral concussion; extensive laceration of scalp; Pottfs 
fracture of left ankle, 147 ; remarks, 148 
lacerations of scalp, infected, 150 

Case 5. Cerebral concussion; infection of extensive laceration of 
scalp; severe cellulitis requiring multiple incisions and drainage, 
150; remarks, 152 
pneumonia, senility and decubitus, 155 

Case 8. Cerebral concussion; pneumonia, decubitus and senility; 
death; autopsy, 155; remarks, 157 
diagnosis, 143 
mild, 143 

Case 1. Cerebral concussion, mild; excellent recovery, 143; remarks, 144 
otoscopic examinations in, value of, 145 
severe, 145 

Case 2. Cerebral concussion, severe; fracture of surgical neck of left 
humerus, 145; remarks, 146 
Convulsions after brain injuries, 13, 36, 341, 343 

in chronic brain injury, 482 
Cranial decompression operation, complications in, 110 
conclusions regarding-, 121 
conditions benefited by, 113 
definition of term, 111 
early diagnosis, importance of, 108 
for acute cerebral edema, 113 
for apoplexy, 113 
in spastic paralysis, 649 
late, futility of, 328, 331 
observations regarding, 108 
of choice, 114 

periods when inadvisable, 119 
plus drainage, 117 

in brain abscess, 120 
in meningitis, early localized, 120 
in hydrocephalus, 119 
principles governing, 118 
plus exploration, 116 

in brain abscess, 116 
in brain tumors, 116 
in epilepsy, 117 , 

qualifications essential to, 112 
risks of earlier methods of, 112 

subtemporal (see Subtemporal decompression operation) 
operation, late, futility of, 351 

Death rate in brain injuries, 3, 4 

operative percentage, 7 
Decompression operation, 6 

in gun-shot and stab wounds, 8 
Decubitus, pneumonia and senility complicating cerebral concussion, 155 
Delirium tremens complicating brain injury, 382. 396 



752 INDEX 

Diabetes a possible factor of post-traumatic neurosis, 404 
Diagnosis of brain injuries, 3, 4 
Diet, in brain injuries, 78 
Drugs, in brain injuries, 78 

Ecchymosis of mastoid area following brain injury, 189 
Edema, cerebral, acute, cranial decompression operation for, 113 
factors predisposing to, 404 
medullary, following cranial injury, 304, 313, 325 

operation inadvisable after development of, 333 
traumatic cerebral, 47 

chronic form, 48 
Epilepsy, cranial decompression and exploration in, 117 
following brain injuries, 36, 72 

following fracture of vault of skull, danger of, 167 
traumatic, 415 

twenty-five months after fracture of vault of skull, 178 
Epileptiform convulsions in brain injury without fracture, 250 

Facial paralysis following brain injury, 191 
right-sided, 287 
temporary, 280 
Fractures of skull of little importance in brain injuries, 415, 556 
about posterior fontanelle, 15 
at base, 14, 187, 189 

facial paralysis following, 188 

mild increase of intracranial pressure, 184 

operation in, 73 

with depressed fracture of vault, 225 

and high intracranial pressure, 233 
and mild intracranial pressure, 225 
at vault, 166 

depressed, in chronic brain injuries, 418 
local anesthesia in operations for, 182 
recent, no operation, 178 

Case 15. Fracture of vault, recent depressed; operation refused; 

recovery doubtful, 178; remarks, 179 
removal of depression, 180 

Case 16. Fracture of vault, depressed ; no signs of increased 
intracranial pressure ; operative removal of depression only, 
180; remarks, 181 
rontgenograms in, 434 
treatment, 224, 227 

with laceration, aseptic precautions, 181 
epilepsy following, 167 
linear, 167 

Case 12. Fracture, linear, of outer table of vault; laceration of scalps- 
multiple injuries; intracranial pressure not increased ; no operation, 
167; remarks, 168. 
Case 13. Fracture of both tables of vault, linear; intracranial pressure 
not increased; no operation, 171; remarks, 172 
shock resulting from, 169 
with increased intracranial pressure, 167 
beneath tentorium, 331 
both tables of vault, epilepsy 25 months after, 178 

with high intracranial pressure due to large extradural hemorrhage, 173 
Case 14- Brain injury, acute severe; wide linear fracture of 
skull; high intracranial pressure due to large extradural 
hemorrhage; left hemiplegia; scalp incision and partial re- 
moval of extradural hemorrhagic clot through fracture of vault, 
173; remarks, 176 
"bursting," 14 
by diastasis, 14 

cerebrospinal fluid, profuse bloody discharge of, after, 211 
" contre-coup," 14 
decompression operation for, 6 



INDEX 753 

Fractures of skull, depressed, diagnosis of, 160 
compound, treatment of, 613 
diagnosis of, 316 
doubtful, 157 

Case 9. Fracture of skull, doubtful; mildly increased intracranial pres- 
sure; fracture of right humerus, right ankle and right scapula; no opera- 
tion, 158; remarks, 159 
Case 10. Fracture of skull, doubtful; intracranial pressure not increased ; 

no operation, 160; remarks, 162 
Case 11. Fracture of skull, doubtful; intracranial pressure increased; 
fracture of femur; no operation; repeated lumbar puncture, 163; re- 
marks, 164 
ecchymosis of mastoid area following, 189 
extending into nose, mouth or ears, 24 
impairment of hearing following, 219 
in brain injuries, 11 
in frontal region, 15 

in posterior portion of vault beneath tentorium, 15 
influence of, on mortality of brain injuries, 302 
occipital bone, 24 
of newborn, 523 

pupillary contraction following, 222 
rontgenograms of, 170 
Rontgen-rays in diagnosis of, 21 
shock, continuance of, after, 210 
squamous bone, 19 
theories of radiation of lines of, 14 
types of, 13 

direct fractures, 13 
indirect fractures, 14 
with increased intracranial pressure, marked, 200 
mild, 184 
repeated lumbar punctures in, 163 

Gunshot injuries of brain, 8, 361 

probing not advisable, 9 

Headache, following lumbar puncture, 66 

in acute brain injuries, 16 
Hearing, impairment of, following brain injury, 269, 280 
Hematoma following cranial injury, 149 
treatment of, 548 

drainage or aspiration, 63. 
Hemorrhage, intracranial, and cerebral edema, ophthalmoscopic findings in, 59 
in the newborn, 645 
with high intracranial pressure, 244 
without paralysis, 646 
Hoffman reflex, 38 

Hydrocephalus, decompression plus drainage in, 119 
following brain injury at birth, 656, 703 
ophthalmoscopic findings in, 57 

Intracranial hemorrhage and cerebral edema, ophthalmoscopic findings in, 59 
in the newborn, 645 
with high intracranial pressure, 244 
without paralysis, 646 
injuries, resistance of patients to,. 340 
pressure, 50 

as measured by spinal mercurial manometer at lumbar puncture, 62 

factors in, 49 

effect of increase of, upon fundus of eye, 54 

fourth stage or moribund period, 52 

high, due to cerebral edema alone, 273 

due to hemorrhage and cerebral edema; subtemporal dooomprossioji opera- 
tion, 243 
lumbar puncture inadvisable in presence of, 333 

48 



754 INDEX 

Intracranial pressure in chronic brain injuries, 427 
increase of, 38 

bilateral decompression operation, 244 

chronic, 36 

effect on medulla, 51 

due to acute cerebral edema, 239 

lowering of, in treatment of brain injuries, 70 
measurement of, 45 
medical stage, 50 
operative stage, 50 
significance of, 49 

signs observable in fundus with ophthalmoscope, 54 
stage of compensation, 50 

of medullary compression or imperative operation, 51 

Lacerations of scalp complicating cerebral concussion, 147 

infection, 150 

prevention of, 148, 150 

treatment of, 170 
Little's disease, 646 

causes of, 68 

treatment of, 646, 648 
Lues, cerebrospinal, complicating brain injury, 397, 399 
Lumbar puncture, 62 

after fracture of base of skull, 184 

anesthetics in, 62 

diagnostic value of, 68 

drainage in treatment of brain injuries, 80 

following cranial injury in children, 553 

headache following, 66 

in brain injuries, 44, 357 

chronic, with convulsions, 482 
of newborn, 524 

medullary complications resulting from, 65 

purpose of, 67 

removal of fluid for examination, 65 

repeated, following cranial injury, 165, 365 
therapeutic value of, 569 

site for, 63 

spinal mercurial manometer in, 62 

technic of, 63 

therapeutic value of, 67 

withdrawal of needle, 66 

Malingering in post-traumatic neurosis, 404, 412 
Manometer, spinal mercurial, 62 

intracranial pressure as measured by, 62 

Landon's, 62 
Meningitic infection following cranial injury, 611, 613, 621 
Meningitis, complicating brain injuries, 361 
decompression plus drainage in, 120 
purulent, following cranial injury, 627, 630 
Mental derangements, complicating brain injury, 154, 391, 509 
Mortality from brain injuries, 3, 4 

operative percentage, 7 

Nausea in acute brain injuries, 16 

Nephritis, a possible factor of post-traumatic neurosis, 404 

complicating chronic brain injuries, 495 
Neurasthenia, post-traumatic, 400 
Neurological surgery, progress of, 108 
Neuroses, post-traumatic, 400 

factors producing, 400 

following brain injuries, 49 

malingering in, 404, 412 

reported cases, 405 






INDEX 755 

Neuroses, post-traumatic. 

Case 94. Cerebral concussion; recovery complicated by post-traumatic 

neurosis, 405 ; remarks, 406 
Case 95. Cerebral concussion, severe; recovery complicated by post- 
traumatic neurosis, 407 ; remarks, 409 
Case 96. Cerebral concussion, severe; recovery complicated by post- 
traumatic neurosis, 409; remarks, 411 
Case 97. Cerebral concussion; recovery complicated by post-traumatic 
neurosis, 412; remarks, 414 
signs associated with, 404 
Newborn, brain injuries of, 521 
acute, 523 

intracranial hemorrhage, 523 
lumbar puncture in, 524 
rupture of supracortical veins, 523 
subtemporal decompression in, 524 
tearing of longitudinal sinus, 523 
fracture of skull of, 523 

Operation for brain injuries, 4 

contra-indications for, 5 

following recovery, 8 

subtemporal decompression and drainage, 6 
Ophthalmoscope, signs of intracranial pressure observable in fundus with, 54 
Ophthalmoscopic examinations in intracranial lesions, 61 

findings in brain injuries, 41 
Osteoplastic flap operation, 86 
Otoscopic examination in brain injuries, 188 

with discharge of blood from ear, 252 

Paralysis following brain injuries, 13, 32 
cerebral spastic, 645 
cause of, 647 

differentiation of patients having convulsive seizures, 678 
in children, with or without marked mental impairment; observations on 
operative treatment of selected cases due to intracranial hemorrhage 
at birth, 644 

Case 176. Brain injury at birth, chronic severe; depressed fracture of 
vault; right spastic hemiplegia wnd convulsive seizures; increased 
intracranial pressure ; modified left subtemporal decompression; re- 
covery, 657; remarks, 661 

Case 177. Brain injury at birth, chronic severe; supracortioal hemor- 
rhage ; right hemiplegia; Jacksonian convulsions ; increased intra- 
cranial pressure; left subtemporal decompression and drainage; 
marked improvement, 663; remarks, 666 

Case 178. Brain injury at birth, chronic severe; supracortical hemor- 
rhage and spastic diplegia; increased intracranial pressure: right 
subtemporal decompression; marked improvement, 667; remarks. 669 

Case 179. Brain injury at birth, chronic severe; supracortical hemor- 
rhage and spastic diplegia; mental retardation and convulsive 
seizures; increased intracranial pressure; left subtemporal decom- 
pression; definite improvement, 669 ; remarks, 673 

Case 180. Brain injury at birth, chronic severe; supracortical hemor- 
rhage; left hemiplegia and convulsive seizures: increased intra- 
cranial pressure: right subtemporal decompression and drainage: 
marked improvement, 674; remarks, 678 

Case 181. Brain injury at birth, chronic severe, with cortical and 
supracortical hemorrhages : spastic diplegia ana 1 retarded mentality; 
increased intracranial pressure : left subtemporal decompression : 
marked improvement, 679; remarks, 682 

Case 182. Brain injury at birth, chronic severe, with supracortical and 
cortical hemorrhage and spastic hemiplegia, mental retardation and 
convulsive seizures: increased intracranial pressure: subtemporal 
right and left decompression and drainage: marked improvei ent, 
682; remarks. 685 



756 INDEX 

Paralysis, cerebral spastic, in children, with or without marked mental impairment; 
observations on operative treatment of selected cases due to intra- 
cranial hemorrhage at birth. 
Case 183. Brain injury at birth, chronic severe, with supracortical 
hemorrhage, spastic diplegia, mental retardation and convulsive 
seizures; increased intracranial pressure; bilateral decompression 
and drainage; marked improvement, 686; remarks, 689 
Case 184. Brain injury at birth, chronic severe, with supracortical 
hemorrhage and spastic diplegia; increased intracranial pressure; 
bilateral subtemporal decompression; marked improvement, 691; 
remarks, 695 
Case 185. Brain injury at birth, chronic severe, with extensive supra- 
cortical hemorrhage and spastic paraplegia and mental retardation; 
increased intracranial pressure; bilateral subtemporal decompres- 
sion; marked improvement, 696 ; remarks, 698 
Case 186. Brain injury at birth, chronic ; convulsive tuAtchings, 
spastic diplegia and increasing intracranial pressure; right sub- 
temporal decompression and drainage of large brain abscess; 
autopsy, 699; remarks, 702 
Case 181. Brain injury at birth, chronic severe, with supracortical 
hemorrhage, severe spastic diplegia, mental impairment and con- 
vulsive seizures; increased intracranial pressure; bilateral decom- 
pression; death from ether two tveeks later; autopsy, 703; re- 
marks, 707 
ophthalmoscopic findings in, 58 
pathologic findings in, 654 
the dura, 655 
hydrocephalus, 656, 703 
intracranial pressure, 655 
permission for autopsy before operation, 653 
points in history of 358 operated patients, 653 
prognosis of, following operation, 652 
treatment of, 646, 648 

cranial decompression operation, 649 

prognosis of, 652 
following operation, 656 
operative, 647, 648 

pathological findings, 654 
technic, 654 
report of 1922 cases examined, 650 
subtemporal decompression operation for, 115 
facial, following cranial injury, 191, 586 
following fracture of skull, 188 
Pneumonia, senility and decubitus complicating cerebral concussion, 155 
Psychasthenia, 400 
Pulse in acute brain injuries, 28 
Pupillary changes in brain injuries, 39, 351 

findings in brain injury with high intracranial pressure and subdural hemor- 
rhage, 246 

Recuperative ability of children having cranial injuries, 543 
Reflexes in brain injuries, 37, 203, 253 
Chaddock sign, 37 
Babinski sign, 38 
Hoffman sign, 38 
Respiration in acute brain injuries, 29 
Restlessness in brain injuries, 35 

Roentgenograms in depressed fractures of vault, 434 ^ 

in fractures of skull, 170 
of cases of brain injury, 283 
Rontgen-rays (see also X-ray) 

in brain injuries, 6, 11, 12, 404 
in diagnosis, 21 

Sarcoma of vault following fracture of skull, 504 

Senility, pneumonia and decubitus complicating cerebral concussion, 155 



INDEX 757 

Sensation, impaired, in brain injuries, 34 
Shock, due to cranial injury, 25, 300 

treatment of, 74, 169, 295, 301, 545, 607 
due to fracture of skull, 169 
nervous, 400 

reaction of children from, 545 
Spastic paralysis (see Paralysis, cerebral spastic, and Cerebral spastic paralysis) 
Spasticity, bilateral, following brain injury, 309, 348, 352, 537 
Sphenoidal sinus disease, brain tumor simulating, 387 
Squamous bone, fracture of the, 19 
Stab- wounds, 8 

probing inadvisable, 9 
Subtemporal decompression operation, 87 
advantages of, 120 

and drainage after appearance of meningitis, 374 
as a means of lessening an increased intracranial pressure, 114 
bone wax in, use of, 95 
for brain tumor, 114 

for high intracranial pressure due to hemorrhage and cerebral edema, 243 
for spastic paralysis, 115, 654 
in brain injury, chronic, 461 
of the newborn, 524 

with high intracranial pressure due to hemorrhage and cerebral 
edema, 322 
moving pictures of, 122 
plus exploration, 116 
post-operative treatment, 106 
purposes of, 111, 114 
technic of, 88 

controlling bleeding, 95 
incising the dura, 99 
insertion of drain, 102 
making incision, 90 
preparation of patient, 88 
suturing and bandaging of wound, 103 
Syphilis a possible factor of post-traumatic neurosis, 404 

Temperature in acute brain injuries, 28 
Traube-Herring waves, 52 
Traumatic cerebral edema, 47 
Treatment of brain injuries, 3, 4 
Tumor of brain, complicating brain injury, 385, 499 
removal of, 110 
of mid-brain, simulating sphenoidal sinus disease, 387 

Unconsciousness in brain injuries, 35 
Urine in brain injuries, 40 

Vault, fractures of, 166 (see Fractures) 

Venesection in acute brain injuries, 32 

Ventricular puncture, in operations for brain injury, 358 

Vomiting in acute brain injuries, 16 

Wax, bone, 95 

"Wet" brain, 8, 12, 36 

i X-ray (see also Rontgen-ray) 

examination in cranial injury, 404 

importance of, 579 
picture in cases of brain injury, 340 



